Prospective Study
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Radiol. Jun 28, 2022; 14(6): 165-176
Published online Jun 28, 2022. doi: 10.4329/wjr.v14.i6.165
Do preoperative pancreatic computed tomography attenuation index and enhancement ratio predict pancreatic fistula after pancreaticoduodenectomy?
Senthil Gnanasekaran, Satish Durgesh, Ramprakash Gurram, Raja Kalayarasan, Biju Pottakkat, M Rajeswari, Bheemanathi Hanuman Srinivas, A Ramesh, Jayaprakash Sahoo
Senthil Gnanasekaran, Satish Durgesh, Ramprakash Gurram, Raja Kalayarasan, Biju Pottakkat, Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
M Rajeswari, Department of Biostatistics, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
Bheemanathi Hanuman Srinivas, Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
A Ramesh, Department of Radiodiagnosis, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
Jayaprakash Sahoo, Department of Endocrinology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
Author contributions: Gnanasekaran S and Kalayarasan R conceptualized the study; Durgesh S and Gurram R performed the research work; Rajeswari M performed the data analysis; Srinivas BH reviewed the histopathological slides for postoperative analysis; Ramesh A performed a preoperative radiological assessment of study participants; Durgesh S and Gurram R wrote the first draft of the manuscript; Gnanasekaran S, Kalayarasan R, Pottakkat B and Sahoo J gave intellectual input and critically revised the manuscript.
Institutional review board statement: The study was reviewed and approved by the institutional ethics committee (Human studies) of Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India (JIP/IEC/2018/500 dated 25-01-2019). The study protocol can be fully accessed at https://jipmer.edu.in/.
Informed consent statement: All study participants, or their legal guardian, provided written consent prior to study enrolment.
Conflict-of-interest statement: All authors of this manuscript have no financial relationships to disclose.
Data sharing statement: No additional data are available.
CONSORT 2010 statement: The authors have read the CONSORT 2010 Statement, and the manuscript was prepared and revised according to the CONSORT 2010 Statement.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Raja Kalayarasan, DNB, MCh, MS, Additional Professor, Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research, Room No. 5442, 4th Floor, Super Specialty Block, Puducherry-605006, India. kalayarasanraja@yahoo.com
Received: January 29, 2022
Peer-review started: January 29, 2022
First decision: April 10, 2022
Revised: April 26, 2022
Accepted: June 20, 2022
Article in press: June 20, 2022
Published online: June 28, 2022
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.

Keywords: Pancreatic fistula, Minimally invasive, Pancreaticoduodenectomy, Pancreatic cancer, Neoplasms, Computed tomography

Core Tip: The prospective observational study evaluated the accuracy of the pancreatic computed tomography indices in predicting clinically relevant pancreatic fistula after pancreaticoduodenectomy. Though the predictive accuracy of pancreatic attenuation index (PAI) was low, pancreatic enhancement ratio (PER) exhibited good accuracy in predicting the development of clinically relevant postoperative pancreatic fistula (CR-POPF). Also, PER showed a statistically significant weak negative correlation with PAI and moderately positive correlation with fibrosis scores suggesting that PER may be an objective preoperative surrogate for assessing pancreatic texture. Preoperative quantification of PER can improve the risk stratification and management of patients at high risk of CR-POPF.