Preoperative imaging evaluation of pancreatic pathologies for the objective prediction of pancreatic fistula after pancreaticoduodenectomy

Abstract

In performing pancreaticoduodenectomy (PD) or when conducting clinical trials involving PD procedure, a universal platform for predicting the risk of postoperative pancreatic fistula (POPF) is indispensable. In this article, the most significant imaging studies that focused on the objective preoperative assessment of pancreatic pathologies in association with the occurrence of POPF after PD were reviewed. Several recently developed imaging modalities can objectively predict the occurrence of POPF after PD by assessing the elasticity, fibrosis, and fatty infiltration of the pancreas. These valuable imaging modalities include: (1) acoustic radiation force impulse ultrasound (US) electrography which provides information about the elastic properties of the pancreas; (2) contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) with/without contrast-enhancement which reflect the histological degree of pancreatic fibrosis; and (3) multi-detector row CT and/or MRI which reflects the microscopic fatty infiltration of the pancreas. The precise and objective preoperative risk assessment of POPF enables surgeons to customize appropriate management strategies for individual patients undergoing PD. This would be also beneficial for stratifying patients for enrolment in relevant studies that involve pancreatic head resection, as objective criteria could be set for the definitive evaluation of collected data related to surgical outcomes across different institutions and surgeons.

Pancreatic Stiffness Quantified with MR Elastography: Relationship to Postoperative Pancreatic Fistula after Pancreaticoenteric Anastomosis

“…Several preoperative imaging indicators of POPF risk have been identified (4)(5)(6)(7)(8), including morphologic features of the pancreatic stump (eg, thickness, area, main pancreatic duct [MPD] diameter), signal intensity at T1-weighted imaging, apparent diffusion coefficient (ADC), and fat fraction. These parameters are used to evaluate the morphologic characteristics or to establish a correlation with histologic changes (eg, fibrosis) of the pancreatic stump (9,10).…”

Personal predictive model based on systemic inflammation markers for estimation of postoperative pancreatic fistula following pancreaticoduodenectomy

“…Guo et al [ 25 ] reported that the texture of pancreas, size of the main pancreatic duct, portal vein invasion and confirmed pathology are the risk factors of postoperative PF. Tajima et al [ 26 ] summarized that preoperative imaging evaluation of pancreatic pathologies would be also beneficial for stratifying. Not surprisingly, systemic inflammatory markers such as neutrophils, lymphocytes, platelets, CRP, albumin, and biomarkers may help predict postoperative PF.…”

Impact of Fatty Pancreas on Postoperative Pancreatic Fistulae: A Meta-Analysis

“…Soft pancreatic parenchyma is the most widely accepted risk factor ( 28 ). Although the mechanism by which FP promotes the occurrence of POPF has not been elucidated, some studies have proposed a possible theory for its pathogenesis ( 29 ): First, during pancreatic and intestinal anastomosis reconstruction, a soft pancreas is more susceptible to ischaemia and injury than a hard pancreas. When suturing between the fragile pancreatic parenchyma and the plasma or muscle layer of the intestine or stomach, the pancreatic ducts and parenchyma are more susceptible to laceration and injury.…”