Preoperative CT scan helps to predict the occurrence of severe pancreatic fistula after pancreaticoduodenectomy

Hadrien Tranchart, Sébastien Gaujoux, Vinciane Rebours, Marie-Pierre Vullierme, Safi Dokmak, Philippe Levy, Anne Couvelard, Jacques Belghiti, Alain Sauvanet
Annals of Surgery 2012, 256 (1): 139-45

OBJECTIVE: To assess the influence of body fat distribution, estimated by a preoperative computed tomographic (CT) scan, on pancreatic fistula (PF) risk after pancreaticoduodenectomy (PD).

BACKGROUND: Pancreatic fatty infiltration is a predictive factor of PF, but accurate preoperative assessment is challenging. We hypothesized that it could be associated with an increased visceral obesity and could be assessed preoperatively.

METHODS: Over 18 months, 103 consecutive patients with PD and pancreaticogastrostomy were studied. Demographic, radiologic, and pathologic data were correlated to PF occurrence. Radiologic data included on a nonenhanced CT acquisition: pancreas, spleen, and liver density measures (Dpancreas, Dspleen, and Dliver [densities of the pancreas, spleen, and liver in hounsfield units], respectively), retro-renal fat thickness, and at the level of the umbilicus, total, visceral, and subcutaneous fat area (TFA [total fat area], VFA [visceral fat area], and SFA [subcutaneous fat area], respectively). Pancreatic fatty infiltration was graded histologically. Logistic regression analysis was used to identify independent predictors of PF-graded B and C according to the International Study Group on the Pancreatic Fistula.

RESULTS: Among the 103 patients, 37% (n = 38) developed a PF (47.4% grade A, 39.5% grade B, and 13.1% grade C). PF risk was correlated with pancreatic fatty infiltration (P = 0.017). In univariate analysis, male gender (P = 0.023), body mass index (BMI) over 25 kg/m (P = 0.02), retro-renal fat thickness over 15 mm (P = 0.006), TFA over the median (>233 cm; P = 0.023), and VFA over the median (>84 cm; P < 0.0001) were significantly associated with an increased risk of symptomatic PF (grade B and C). In multivariate analysis, VFA greater than 84 cm (OR = 8.16, P = 0.002) was the only independent predictive factor of grade B or C PF. Using the same model, a VFA greater than 84 cm was the only independent factor associated with the presence of fatty pancreas on pathologic examination.

CONCLUSIONS: Preoperative assessment of body fat distribution by a CT scan, as a surrogate for fatty pancreas infiltration, can help to predict the occurrence of clinically significant PF after PD.

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