Density and enhancement of the pancreatic tail on computer tomography predicts acinar score and pancreatic fistula after pancreatoduodenectomy

Abstract

Background: Acinar score calculated at the pancreatic resection margin is associated with postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD). The present study evaluates the association between (i) computed tomography (CT) density of the pancreas and the acinar score of the pancreatic resection margin, and (ii) CT density of the pancreas and POPF after PD.Methods: Consecutive patients who underwent PD were included for analysis. CT densities of the pancreatic head, neck, body and tail were measured in non-contrast (NC), arterial (ART) and portal venous (PV) phases. Histologic slides of the pancreatic resection margin were scored for acinar cell density.Results: Ninety patients were included for analysis. Non-contrast density of the pancreatic tail was a good predictor of POPF (AUROC 0.704, p = 0.036), and a cut-off value of >40 Hounsfield units predicted POPF with 70.0% sensitivity and 73.4% specificity. The ratio of densities between PV and NC phases in the pancreatic tail was also a good predictor of POPF (AUROC 0.712, p = 0.030), and a cut-off value of <2.29 predicted POPF with 70.9% sensitivity and 80% specificity. Conclusion:Non-contrast CT density of the pancreatic tail correlates with acinar cell density of the pancreatic resection margin and predicts the development of POPF after PD.

A modified alternative fistula risk score (a-FRS) obtained from the computed tomography enhancement pattern of the pancreatic parenchyma predicts pancreatic fistula after pancreatoduodenectomy

“…6,20 All these shortcomings of the a-FRS limit its widespread acceptance. To reflect the pancreatic texture more objectively and precisely, various preoperative imaging methods have been evaluated, including ultrasound, 21,22 magnetic resonance (MR) 16,23 and CT. [9][10][11][12][13]24 Among these modalities, multiphase enhanced CT scans have the advantages of being noninvasive and objective and having good repeatability with stable parameters. Moreover, CT is normally necessary to diagnose and stage peri-ampullary tumors before surgery; therefore, CT has a better potential to reflect the pancreatic texture and to predict CR-POPF after PD.…”

“…Similarly, a study of 146 patients reported by Kang et al 11 demonstrated that the enhancement ratio (equilibrium phaseprecontrast)/(precontrast attenuation ratio) in the equilibrium phase (3 min after the start of injection of contrast) was significantly higher in the non-POPF cases than in the POPF cases (P = 0.001). Nahm et al 12 revealed that the portal/noncontrast phase (P/N) ratio in the pancreatic tail was predictive of CR-POPF (AUC 0.712, P = 0.030) and positively correlated with pancreatic collagen-rich fibrosis. Recently, Maehira et al 13 reported that an arterial/portal phase (A/P) ratio 1.19 (P < 0.001, OR 10.3) and portal/late phase (P/L) ratio 1.17 (P < 0.001, OR 3.23) were independent risk factors for CR-POPF, and histological analysis revealed that both ratios were correlated with a lower degree of fibrosis.…”

“…In recent years, many studies have revealed that the enhancement pattern of the pancreatic parenchyma on preoperative CT was significantly associated with the degree of pancreatic fibrosis and risk of POPF. [9][10][11][12][13] Specifically, a rapid-decrease enhancement pattern (high CT attenuation value in the arterial phase and low CT attenuation value in the portal and late phases) indicates a soft texture with a high risk of POPF, while a delayed enhancement pattern suggests a firm texture with a low risk of POPF. The quantitative evaluation of pancreatic texture by CT scan is both objective and preoperatively available.…”

Increased postoperative pancreatic fistula rate after distal pancreatectomy compared with pancreatoduodenectomy is attributable to a difference in acinar scores

“…Acinar score may be predicted preoperatively and assessed intraoperatively. We have previously demonstrated the utility of preoperative CT scans in predicting both acinar score and POPF 18 . This work showed that non‐contrast evaluation of the pancreatic tail correlated strongly and significantly with the acinar score (ρ = 0.619, P < .001) and also day 1 drain amylase values (ρ = 0.455, P < .001) after pancreatoduodenectomy.…”

The efficacy of the 3-dimensional vibe-caipirinha-dixon technique in the evaluation of pancreatic steatosis

“…CT is one of the tools for quantification of fat in the pancreas [10]. Pancreas to spleen density ratio (P/S) via CT is the current indicator of interest for the prediction of postoperative pancreatic fistula development before pancreatoduodenectomy procedure and endocrine and exocrine insufficiency or disorders [10,27,28]. Fukie et al reported that MR-based pancreatic fat quantification was superior to CT-based quantification for estimating the probability of pancreatic cancer [29].…”