Possibility of computer tomography with contrast enhancement in evaluation of the structure of the pancreas and prediction of pancreatic fistula in pancreas resection

One of the most common complications after pancreatic resections is an external pancreatic fistula. The main risk factor for pancreatic fistula is the “soft” structure of the pancreas. The aim of the study is to determine the possibility of computed tomography with contrast enhancement at the preoperative period in an objective assessment of the structure of the pancreas with pancreatoduodenal resections and prediction of pancreatic fistula in the postoperative period. Retrospectively, 102 patients were selected. Patients were divided into 2 groups depending on the structure of the pancreas according to computed tomography at the preoperative period. According to the data of preoperative CT with contrast enhancement, the structure of the pancreas was evaluated; density characteristics in native, arterial, venous, delayed phases (HU); pancreatic duct diameter. Group 1 included 37 patients with a “soft” pancreas. 65 patients with a “solid” pancreas were in group 2. In group 1, in 16 cases (43%), a clinically significant PF was formed in the postoperative period; in 21 cases (57%), the postoperative period proceeded uncomplicated. In group 2, in 5 cases (8%), the postoperative period was complicated by clinically significant PF; in 60 cases (92%), the postoperative period was uncomplicated. The development of clinically significant PF positively correlates with the “soft” pancreas (r = 0.374, p<0.001), the density of pancreas of the native phase (r = 0.179, p = 0.099), the density of pancreas in the arterial phase (r = 0.208, p =0.054). Negatively correlates with the “solid” pancreas (r = -0.274, p<0.001) and the pancreatic duct diameter (r = -0.339, p = 0.001). The “soft” pancreas positively correlates with the density pancreas in the native phase (r = 0,559, p<0,001) and the density pancreas in the arterial phase (r = 0,710, p<0,001) and negatively correlates with the pancreatic duct diameter (r = - 0,534, p<0,001) and the density pancreas in the excretory phase (r = -0,409, p<0,001). Using computed tomography with contrast enhancement at the preoperative period, an objective assessment of the pancreatic structure is possible due to its density characteristics in the native and arterial phases of the scan to highlight a high-risk group for the development of clinically significant PF.

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Diagnostic criteria for a “soft” pancreas and their influence on the occurrence of pancreatic fistula after pancreatoduodenal

Annaly khirurgicheskoy gepatologii = Annals of HPB surgery ◽

10.16931/1995-5464.20202113-123 ◽

2020 ◽

Vol 25 (2) ◽

pp. 113-123

Author(s):

Yu. S. Galchina ◽

G. G. Kаrmаzаnovsky ◽

D. V. Kalinin ◽

E. V. Kondratyev ◽

D. S. Gorin ◽

...

Keyword(s):

Computed Tomography ◽

Pancreatic Fistula ◽

Pancreatic Duct ◽

Contrast Enhancement ◽

Acinar Cells ◽

Enhancement Ratio ◽

Pancreatic Parenchyma ◽

Duct Diameter ◽

Clinically Significant ◽

Parenchyma Enhancement

Purpose. Identification of the possibilities of contrast enhancement computed tomography in evaluated the number of the acinar structures in the pancreatic parenchyma at the preoperative stage to predict the development pancreatic fistula.Material and methods. In 2016–2019, 196 pancreatoduodenectomy were performed. 86 patients were retrospectively selected. Patients were divided into 2 groups: group 1 included 16 observations with the development of clinically significant pancreatic fistula, in 2 – 70 cases without complications. According to preoperative contrast enhancement computed tomography, structure of the pancreas, pancreatic parenchyma thickness, pancreatic duct diameter, the density of the pancreas in the native phase, relative parenchyma enhancement ratio, washout coefficient, pancreas stump volume were evaluated. According histological, the number of acinar and fat cells in the section of the removed pancreas was evaluated.Results. “Soft” structure of the pancreas (r = 0.374, p = 0.000), pancreatic parenchyma thickness (r = 0.549, p = 0.000), the density of the pancreas in the native phase of the scan (r = 0.568, p = 0.000), the values relative parenchyma enhancement ratio (r = 0.63, p = 0.000), pancreas stump volume (r = 0.508, p = 0.000) positively correlated with clinically significant pancreatic fistula and the number of acinar cells. Pancreatic duct diameter (r = −0.339, p = 0.001) negatively correlated with clinically significant pancreatic fistula and the number of acinar cells. Pancreatic fistula risk is 3.09 times higher with the number of acini more than 72.5%, sensitivity 75%, specificity 75.71%. Pancreatic fistula risk is 1.8 times higher with the density of the pancreas in the native phase over 35.5 HU sensitivity 62%, specificity 65%. Pancreatic fistula risk is 2.76 times higher with values parenchyma accumulation coefficient more than 1, sensitivity 75%, specificity 73%.Conclusions. Contrast enhancement computed tomography allows evaluating acinar index in the preoperative period to pick out the high-risk patient group to development of pancreatic fistula.

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Pancreatic fistula in proximal pancreas resection: correlation of computed tomography and morphological predictors

Medical Visualization ◽

10.24835/1607-0763-2020-1-29-38 ◽

2020 ◽

Vol 24 (1) ◽

pp. 29-38

Author(s):

Yu. S. Galchina ◽

G. G. Kаrmаzаnovsky ◽

D. V. Kalinin ◽

E. V. Kondratyev ◽

D. S. Gorin ◽

...

Keyword(s):

Computed Tomography ◽

Postoperative Complications ◽

Pancreatic Fistula ◽

Contrast Enhancement ◽

Postoperative Period ◽

High Risk Patient ◽

Fat Cells ◽

Preoperative Period ◽

Accumulation Coefficient ◽

Venous Phase

Purpose: identification of the possibilities of computer tomography with contrast enhancement in evaluated of the degree of fibrosis and number of acinar structures in the pancreatic parenchyma at the preoperative period to predict the development of postoperative complications.Material and methods: In the department of abdominal surgery in 2016-2019, 196 pancreatoduodenal resections were performed. Retrospectively selected group of patients (49). Patients were divided into 2 groups according with the postoperative period. The postoperative period was uncomplicated in 41 (84%) cases. Сlinically significant pancreatic fistula was in 8 (16%) cases. According to preoperative computed tomography with contrast enhancement, we evaluated: the structure of the pancreas; the density of the pancreas in the native phase of the scan (HU), parenchyma accumulation coefficient; parenchyma accumulation coefficient in the venous phase; parenchyma accumulation coefficient in the excretory phase; coefficient of relative washout of contrast enhancement of parenchyma. According histological we evaluated the number of fibrosis and acinar, fat cells in the section pancreas.Results: "Soft" structure of the pancreas (r=0,747, p=0,000), parenchyma accumulation coefficient (r=0,631, p=0,000), the density of the pancreas in the native phase of the scan (r=0,568, p=0,000) positively correlated with complicated postoperative period and the number of acinar cells. Parenchyma accumulation coefficient in the excretory phase (r=0,562, p=0,000) positively correlated with the fibrosis pancreas and in the negatively correlated with the complicated postoperative period. The risk of developing pancreatic fistula is 3 times higher with values parenchyma accumulation coefficient greater than 1, sensitivity 75%, specificity 73%. The risk of developing pancreatic fistula is 3 times higher with values parenchyma accumulation coefficient in the excretory phase less than 0.45, sensitivity 75%, specificity 63%.Conclusions: computed tomography with contrast enhancement allows the structure pancreas, the number of fibrosis and acinar cell sat the preoperative period to pick out the high-risk patient group to the development of postoperative complications.

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Validation of Mucosal Sutureless Pancreatojejunostomy after Pancreatoduodenectomy

The American Surgeon ◽

10.1177/000313481408000222 ◽

2014 ◽

Vol 80 (2) ◽

pp. 149-154 ◽

Cited By ~ 1

Author(s):

Yoichi Ishizaki ◽

Jiro Yoshimoto ◽

Hiroyuki Sugo ◽

Hiroshi Imamura ◽

Seiji Kawasaki

Keyword(s):

Pancreatic Fistula ◽

Pancreatic Duct ◽

Postoperative Mortality ◽

International Study ◽

Study Group ◽

International Study Group ◽

Duct Diameter ◽

Pancreatic Duct Stenting ◽

Clinically Significant ◽

Low Rate

Although duct-to-mucosa pancreatojejunostomy has been considered safer than other techniques, this procedure is particularly difficult when the pancreatic duct is small. It has therefore become increasingly necessary to develop a simple mucosal sutureless pancreatojejunostomy technique to replace the conventional hand-sewing one. Two hundred fourteen patients who underwent mucosal sutureless pancreatojejunostomy were classified into two groups: those with a normal pancreatic duct diameter (less than 3 mm, n = 97) and those with a dilated pancreatic duct (3 mm or greater, n = 117). The rate of clinically significant pancreatic fistula (Grade B or C by the International Study Group on Pancreatic Fistula definition) among the patients as a whole was 8 per cent. The overall incidence of pancreatic fistula was significantly higher in the patients with a pancreatic duct diameter of less than 3 mm than in those with a pancreatic duct diameter of 3 mm or greater. However, the incidence of clinically significant pancreatic fistula did not differ between the groups (less than 3 mm, 11%; 3 mm or greater, 5%; P = 0.09). Grade C pancreatic fistula developed in one patient with a pancreatic duct diameter of less than 3 mm and in two with a pancreatic duct diameter 3 mm or greater. Although two patients required reoperation, all of the fistulas were cured and the postoperative mortality rate related to pancreatoduodenectomy was zero. Mucosal sutureless pancreatojejunostomy combined with pancreatic duct stenting is associated with a low rate of clinically significant pancreatic fistula even in patients with a small pancreatic duct diameter less than 3 mm.

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Pancreatic fistulae following pancreatic resection. Analysis of causes and prevention methods

Reports of Vinnytsia National Medical University ◽

10.31393/reports-vnmedical-2018-22(4)-11 ◽

2018 ◽

Vol 22 (4) ◽

pp. 640-646

Author(s):

K.G. Valikhnovska

Keyword(s):

Risk Factors ◽

Pancreatic Fistula ◽

Pancreatic Duct ◽

Pancreatic Resection ◽

Pancreatic Head ◽

Preoperative Period ◽

External Drainage ◽

Distal Pancreatic Resection ◽

Glycemic Level ◽

Prevention Methods

The causes of pancreatic fistula were analyzed in 503 patients aged from 22 to 81who underwent pancreaticoduodenectomy for pancreatic and periampullary tumors. The said patients were operated on during the period from 2008 to 2017. The aim of this study is to improve the outcomes of pancreatic resection based on a retrospective analysis of the risk factors of postoperative pancreatic fistulae and the development of a range of measures to prevent the above complication. The influence of factors on the risk of pancreatic fistula was investigated by Pearson method (χ2). The factors contributing to the occurrence of pancreatic fistulae included type of resection (Whipple pancreaticoduodenectomy, pylorus preserving pancreaticoduodenectomy; χ2=8.616,1, p=0.0033, p<0.01), kind of pathology (cancer of the pancreatic head, χ2=7.658,1, p=0.0057, p<0.01), type of pancreaticojejunostomy (invaginative pancreatic duct-jejunostomy; χ2=12.75,1, p<0.001), technique for drainage of the major pancreatic duct (pancreaticojejunostomy on external drainage, χ2=44.01,1, p<0.0001), resection of venous vessels following distal pancreatic resection (χ2=8.350,1, p=0.0039, p<0.01), glycemic level in the preoperative period (P=0.0344,U=15061), the presence of concomitant diseases in patients (χ2=15.62,1, p=0.0001, p<0.001). Preoperative glycemic level and the presence of concomitant diseases in patients are factors that can be influenced to prevent the onset of pancreatic fistula in the postoperative period in patients who are scheduled for pancreatic resection. Prevention of this complication involves the correction of glycemic level and treatment of concomitant pathology in patients in the preoperative period.

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The efficacy of polyglycolic acid felt reinforcement in preventing postoperative pancreatic fistula after pancreaticojejunostomy in patients with main pancreatic duct less than 3 mm in diameter and soft pancreas undergoing pancreatoduodenectomy (PLANET-PJ trial): study protocol for a multicentre randomized phase III trial in Japan and Korea

Trials ◽

10.1186/s13063-019-3595-x ◽

2019 ◽

Vol 20 (1) ◽

Cited By ~ 1

Author(s):

Kazuto Shibuya ◽

Jin-Young Jang ◽

Sohei Satoi ◽

Masayuki Sho ◽

Suguru Yamada ◽

...

Keyword(s):

Pancreatic Fistula ◽

Pancreatic Duct ◽

Study Protocol ◽

Main Pancreatic Duct ◽

Polyglycolic Acid ◽

Postoperative Pancreatic Fistula ◽

Phase Iii ◽

Phase Iii Trial ◽

Soft Pancreas

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A score model based on pancreatic steatosis and fibrosis and pancreatic duct diameter to predict postoperative pancreatic fistula after Pancreatoduodenectomy

BMC Surgery ◽

10.1186/s12893-019-0534-4 ◽

2019 ◽

Vol 19 (1) ◽

Cited By ~ 7

Author(s):

Guo Xingjun ◽

◽

Zhu Feng ◽

Yang Meiwen ◽

Jiang Jianxin ◽

...

Keyword(s):

Pancreatic Fistula ◽

Pancreatic Duct ◽

Postoperative Pancreatic Fistula ◽

Model Based ◽

Duct Diameter ◽

Score Model ◽

Pancreatic Steatosis

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Multiphasic Multidetector Computed Tomography Study of a Rare Tracheal Tumor: Granular Cell Tumor

Case Reports in Pulmonology ◽

10.1155/2014/807430 ◽

2014 ◽

Vol 2014 ◽

pp. 1-4 ◽

Cited By ~ 1

Author(s):

Tommaso Guarnieri ◽

Luciano Cardinale ◽

Gianluca Macchia ◽

Giancarlo Cortese ◽

Andrea Veltri

Keyword(s):

Computed Tomography ◽

Multidetector Computed Tomography ◽

Contrast Enhancement ◽

Granular Cell Tumor ◽

Multidetector Ct ◽

Polypoid Lesion ◽

Granular Cell ◽

Cell Tumor ◽

Arterial Phase ◽

Granular Cell Tumour

Our aim is to present the case report of a woman affected by tracheal granular cell tumor analysed by multiphasic contrast-enhanced multidetector CT. The tumor presents as polypoid lesion (diameter 13 mm), with smooth and well-defined margins, elevated contrast enhancement in arterial phase, and a modest release of contrast in venous phase. This pattern is quite different from the other tracheal tumours. We have performed a comprehensive review of literature to assess all cases of granular cell tumors of the trachea; only 40 cases are reported. Of these, no one focused on the contrast enhancement aspect, so our work is the first showing a specific pattern in multidetector computed tomography (MDCT) of the tracheal granular cell tumour and may help in differential diagnosis.

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Comparison Between Dunking (Invagination) Pancreaticojejunoanastomosis and Double Layer Duct to Mucosa Anastomosis After Cephalic Duodenopancreatectomy-Whipple Procedure for Pancreatic Cephalic Carcinoma

PRILOZI ◽

10.2478/prilozi-2020-0044 ◽

2020 ◽

Vol 41 (3) ◽

pp. 39-47

Author(s):

Aleksandar Shumkovski ◽

Ljubomir Ognjenovic ◽

Stojan Gjoshev

Keyword(s):

Overall Survival ◽

Pancreatic Fistula ◽

Pancreatic Duct ◽

Double Layer ◽

Main Pancreatic Duct ◽

Pancreatic Head ◽

Postoperative Pancreatic Fistula ◽

Postoperative Reflux ◽

Soft Pancreas ◽

Significant Difference

AbstractIntroduction: Pancreatic cancer is malignancy with poor prognosis for quality of life and overall survival. The incidence is variant, 7.7/100,000 in Europe, 7.6/100,000 in the USA, 2.2/100.000 in Africa. The only real benefit for cure is surgery, duodenopancreatectomy. The key points for this procedure are radicality, low morbidity and low mortality, the follow up and the expected overall survival. The benchmark of the procedure is the pancreaticojejunoanastomosis, with its main pitfall, postoperative pancreatic fistula B or C. Subsequently, the manner of creation of pancreaticojejunoanastomosis defines the safety, thus the postoperative morbidity and mortality. Finally, this issue remarkably depends on the surgeon and the surgical technique creating the anastomosis. We used 2 techniques with interrupted sutures, dunking anastomosis and duct-to-mucosa double layer technique. The objective of the study was to compare these 2 suturing techniques we applied, and the aim was to reveal the risk benefit rationale for dunking either duct to mucosa anastomosis.Material and method: In our last series of 25 patients suffering pancreatic head carcinoma we performed a standard dodenopancreatectomy. After the preoperative diagnosis and staging with US, CICT, tumor markers, they underwent surgery. Invagination-dunking anastomosis was performed in 15, whereas, duct-to-mucosa, double layer anastomosis was performed in 10. In the first group with dunking anastomosis, we had 6 patients with soft pancreas and 8 with narrow main pancreatic duct, less than 3 mm. In the duct-to-mucosa group there were 5 patients with soft pancreas and 4 with narrow main pancreatic duct. All other stages of surgery were unified, so the only difference in the procedure remained on the pancreatojejunoanastomosis. The onset of the postoperative pancreatic fistula was estimated with revelation of 3 fold serum level of alfa amylases from the third postoperative day in the drain liquid.Results: In the duct to mucosa group there wasn’t a clinically relevant postoperative pancreatic fistula, while in the dunking anastomosis group we had 4 postoperative pancreatic fistula B, 26 %. One of these 4 patients experienced intraabdominal collection – abscess, conservatively managed with lavation through the drain. Comparing the groups, there was no significant difference between the groups concerning the appearance of postoperative pancreatic fistula: p>0.05, p=0.125. From all 25 patients, in 21 patients biliary stent was installed preoperatively to resolve the preoperative jaundice. All 21 suffered preoperative and postoperative reflux cholangitis, extending the intra-hospital stay.Conclusion: So far, there have been many trials referring to opposite results while comparing these 2 techniques in creation of the pancreticojejunoanastomosis. In our study, the duct to mucosa anastomosis prevailed as a technique, proving its risk benefit rationale. However, further large randomized clinical studies have to be conducted to clarify which of these procedures would be the prime objective in the choice of the surgeon while creating pancreatojejunoanastomosis.

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Pancreatic fistula risk assessment after distal pancreatectomy: a retrospective controlled study

Kuban Scientific Medical Bulletin ◽

10.25207/1608-6228-2021-28-2-33-45 ◽

2021 ◽

Vol 28 (2) ◽

pp. 33-45

Author(s):

E. S. Drozdov ◽

E. B. Topolnitskiy ◽

S. S. Klokov ◽

T. V. Dibina

Keyword(s):

Risk Factors ◽

Pancreatic Fistula ◽

Pancreatic Duct ◽

Distal Pancreatectomy ◽

Main Pancreatic Duct ◽

Postoperative Pancreatic Fistula ◽

Controlled Study ◽

Morphological Examination ◽

Distal Pancreatic Resection ◽

Duct Diameter

Background. Despite declining mortality, postoperative pancreatic fistula (PPF) remains a common complication of distal pancreatic resection surgery challenging to clinical prediction.Objectives. Prognostic analysis of the postoperative pancreatic fistula risk factors in patients with previous distal pancreatectomy.Methods. A retrospective controlled assay enrolled 107 patients, including 63 (58.9%) male and 44 (41.1%) female patients. All patients underwent distal pancreatectomy followed by a morphological examination of resected material. All patients had a general and biochemical blood panel profiling. Pancreatic tissue density at a putative resection zone was assessed with computed tomography. The patients were allocated to two cohorts: (1) not developing PPF (77 patients) and (2) having postoperative PPF complications (30 patients.Results. No statistically significant differences by age, gender, ASA and BMI scores were observed in study cohorts. Multivariate analysis revealed a statistically significant correlation of the PPF rate with the following factors: main pancreatic duct diameter <3 mm (odds ratio (OR) 1.02, 95% confidence interval (CI) 1.01–1.05, p = 0.01), pancreatic density at putative resection zone <30 HU in CT (OR 3.18, 95% CI 1.38–7.74, p < 0.01) and differential albumin of postoperative day 1 vs. pre-surgery >14 g/L (OR 3.13, 95% CI 1.19–8.24, p < 0.01).Conclusion. A main pancreatic duct diameter <3 mm, pancreatic density at putative resection zone <30 HU in CT and differential albumin of postoperative day 1 vs. pre-surgery >14 g/L are independent risk factors of postoperative fistulae.

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