Utility of CT in the Diagnosis of Pancreatic Fistula After Pancreaticoduodenectomy in Patients with Soft Pancreas

Abstract

W175as "drain output of any measurable volume of fluid on or after postoperative day 3 with an amylase content greater than three times the serum amylase activity" [11].The overall rate of pancreatic fistula after pancreaticoduodenectomy ranges from 17% in patients in whom the pancreatic remnant has a hard consistency [12] and exocrine pancreatic function and pancreatic juice output are impaired [13] to 25% in cases in which the pancreas is soft [1], that is, the parenchyma is normal [13]. Soft pancreatic texture [1,3,13] and small pancreatic duct size [3] are the most important preoperative risk factors for the development of pancreatic fistula.The diagnosis of pancreatic fistula usually is made an average of 7 days after pancreaticoduodenectomy [5,14,15]. Pancreatic fistula diagnosed with repeated assays of pancreatic enzymes in peripancreatic fluid drainage [11,14,16] © American Roentgen Ray Society P ancreaticoduodenectomy is safe in the management of various malignant and benign diseases of the pancreatic head and periampullary region. Although the mortality rate has decreased to approximately 1-2% at high-volume centers, the morbidity rate ranges from 30% to 50% [1][2][3][4]. The two most frequent complications of pancreaticoduodenectomy are delayed gastric emptying and pancreatic fistula. G a s t r oi nt e s t i n a l I m ag i ng • O r ig i n a l R e s e a rc hPancreatic fistula after pancreaticoduodenectomy is a serious complication resulting in prolonged hospital stay, increased costs, readmission, and a mortality rate of 3-9% [5,6]. Efforts to reduce the incidence of pancreatic fistula have included definition of risk factors [1,7], improvement of surgical technique [8,9], and perioperative administration of somatostatin and its analogues [1,10]. The International Study Group on Pancreatic Fistula has defined pancreatic fistula OBJECTIVE. The purpose of this study was to evaluate the sensitivity and specificity of routine performance of CT on postoperative day 7 in patients at high risk of pancreatic fistula after pancreaticoduodenectomy.MATERIALS AND METHODS. Two radiologists analyzed images from CT examinations of 50 patients with soft pancreas 7 days after pancreaticoduodenectomy. Pancreatic fistula was defined at CT as a fluid collection close to the pancreaticogastric or pancreaticojejunal anastomosis. Clinicobiologic criteria for the diagnosis of pancreatic fistula were drain output of any measurable volume of fluid on or after postoperative day 3 that had an amylase content more than three times the serum amylase activity. The final diagnosis of pancreatic fistula was rendered on the basis of clinicobiologic data at hospital discharge or at first readmission.RESULTS. At hospital discharge or at first readmission, 27 of 50 patients (54%) had a pancreatic fistula. On postoperative day 7, 30 patients (60%) had a total of 51 fluid collections, and CT showed a fluid collection close to the pancreaticogastric or pancreaticojejunal anastomosis in 21 of 51 cases. CT had a sensitivity of 63% (17/27 pat...

A grading system can predict clinical and economic outcomes of pancreatic fistula after pancreaticoduodenectomy: results in 755 consecutive patients

“…Our results on the higher incidence of grade A POPF in patients with bile duct or ampullary tumors is in some way expected, because of the well-known correlation between soft pancreatic texture and onset of pancreatic fistula [8,9,12,[18][19][20]. However, the observation that such difference is nullified for grades B and C makes us believe that the clinical impact of the fistula and all the associated complications do not depend on the pathological diagnosis, but on other factors like the nutritional status of the patient [15,18,[20][21][22][23][24] or the aggressiveness of the primary disease.…”

“…In fact, the biochemical definition of the ISGPF should actually be subject of a revision based on new data published, regarding the correlation between amylase levels in the drained fluid and pancreatic fistula [8,9]. Strasberg et al [10] have underlined as well the limits of this strict biochemical definition in a recent study, but the drawn conclusions about the entire ISGPF work are largely debatable.…”

“…Reoperation was necessary in case of sepsis sustained by complex collections not sufficiently drained by percutaneous procedures, in case of complete dehiscence of the anastomosis, with evidence of air bubbles near the anastomosis at the CT scan [8,9,11] and/or septic status and in case of late bleeding provoked by the fistula.…”

Diagnosis and management of postoperative pancreatic fistula

“…However, it has been found that in PD, true-positive and false-positive perianastomotic collections behaved differently. False-positive collections were smaller and never contained air bubbles and-most importantlydisappeared rapidly at follow-up CT in all cases, unlike perianastomotic collections due to fistula [15].…”

“…Although the evidence in this field is limited, the few recent studies available suggested that fluid collections around the pancreaticojejunostomy site or in the pancreatic bed were significantly correlated with POPF and that-under postoperative conditions without a POPF-a fluid collection does not usually accumulate in these areas [13,14]. In a study on the accuracy of routine contrast-enhanced CT for the diagnosis of POPF, the sensitivity was 63 %, and the specificity was 83 % [15]. Contrast-enhanced CT can differentiate between collections in contiguity with the pancreatic duct or the anastomotic suture line and other collections, according to site (superior recess of lesser sac, subhepatic space, paracolic gutters, root of mesentery).…”