Keywords
pancreatic attenuation index - postoperative pancreatic fistula - pancreatic steatosis
Introduction
Global prevalence of obesity is more than 650 million and coming to the Indian scenario
it is 135 million.[1] The major health hazard associated with obesity is visceral fat deposition, which
can lead to various metabolic complications.
Pancreatic steatosis is a by-product of visceral fat deposition. The clinical significance
of pancreatic steatosis is the acquired proinflammatory status of the pancreas.[2]
In the early 1960s, the morbidity and mortality associated with pancreatic surgery
were 60 and 25%, respectively. Presently, the mortality has reduced to 2 to 5%, but
the morbidity remains almost the same.[3] Postoperative pancreatic fistula (POPF) is one among the dreaded complications associated
with pancreatic surgeries. The texture of pancreas is a strong contributing risk factor.
Clinically significant POPF (grade B/C) is seen in 11 to 37% of patients with soft
pancreas and 1 to 6% patients with firm pancreas.[4]
[5]
[6]
[7] Fat deposition in pancreas (pancreatic steatosis) translates to a soft pancreas.
The gold standard for the identification of pancreatic texture is intraoperative palpation
by an experienced surgeon.[8]
Various imaging modalities can be used to predict pancreatic texture like ultrasonography
(USG), magnetic resonance imaging (MRI), and computed tomography (CT). USG can assess
the echogenicity as well as utilize the concept of elastography. MRI can detect the
level of fibrosis in pancreas by various methods. Generally, pancreas is hyperintense
in T1-weighted images and this can be lost in significant fibrosis. Diffusion-weighted
images and MR elastography can also aid in the assessment.
Liver attenuation index has been widely used by radiologists to assess the fat content
in the liver. Kim et al have shown the utilization of pancreatic attenuation index
(PAI) to assess the fat content in pancreas.[9] A CT abdomen is a part of standard workup for pancreatic surgeries and it can aid
us get a preoperative assessment of the fat content of the pancreas.
Methodology
This is a prospective observational study undertaken in our department from February
2021 to January 2023. The study was initiated after getting clearance from the institutional
ethics committee and informed consent was taken from the study participants.
Inclusion criteria: Consecutive patients who underwent any type of pancreatic resections during the
study period such as Whipple procedure, distal pancreatectomy (DP), median pancreatectomy,
and Whipple + DP were included. Data of these patients were prospectively collected
that included preoperative, intraoperative, and postoperative parameters. Patients
with chronic calcific pancreatitis, diffuse pancreatic atrophy, severe ductal dilatation,
and tumor infiltration that preclude histological or radiological assessment were
excluded.
-
Radiology study tool
The patients planned for resection underwent contrast-enhanced CT with pancreatic
protocol. The CT was taken with a multidetector row CT unit (Gold seal Optima CT 660;
GE Healthcare System, Boston, United States). Scans were triggered using the bolus
tracking technique when the threshold of 150 Hounsfield unit was reached in the upper
abdominal aorta. Contrast-enhanced scans included late arterial phase at 30 to 40 seconds
from the start of contrast injection (12–15 seconds after bolus tracking), portal
venous phase at 60 to 70 seconds (25–30 seconds delay after the arterial phase), and
equilibrium phase at 3 minutes from contrast injection. The plain and contrast-enhanced
images were reconstructed at 3 mm thickness. The CT images were viewed in revolution
EVO image viewer (GE Healthcare System, Boston, United States) and were reviewed by
a designated radiologist of more than 25 years experience. The plain CT and contrast
images were viewed side by side. The PAI was measured in the prospective pancreatic
specimen distal to (for DP) or proximal to (for Whipple procedure) the line of resection
in plain CT images. CT attenuation values were measured in nontumorous pancreatic
tissue at three sites average size of 10 to 30 mm2 ([Fig. 1]). The plain CT images were compared with the contrast-enhanced images in arterial,
portal and equilibrium phases to avoid vascular structures and pancreatic duct, which
may result in wrong interpretation. Mean of the three values were taken as the mean
pancreatic attenuation. Three similar areas were selected in the spleen and mean splenic
attenuation was calculated.
-
Pathology study tool
The resected specimens were evaluated by a designated pathologist of more than 10
years experience. The pathologist was blinded to the intraoperative pancreatic texture
and PAI. The specimen was grossed and nontumorous area adjacent to the line of resection
was analyzed. Formalin fixed paraffin embedded sections were taken and stained with
hematoxylin and eosin. The slides were examined using light microscope (Labomedlx
500, Labomed, Inc., Los Angeles, United States) in scanner view, low power and high
power for intralobular and interlobar fat ([Fig. 2]). The fat-laden areas were identified in low power and confirmed in high power ([Fig. 3]). Three random areas were taken and the images were uploaded. The uploaded images
were assessed with Adobe PhotoshopR CS6 (Adobe Systems Inc., San Jose, California, United States). The quantitative measurement
of the fat content was calculated using the measurement log tool ([Fig. 4]). The area of fat in each image was calculated and the average was taken as the
mean pancreatic fat content.
-
Perioperative assessment tools
Preoperative demographic data including age, gender, body mass index (BMI), pancreatic
duct diameter (measured radiologically), preoperative diabetic status, and American
Society of Anaesthesiologists (ASA) grade were recorded. Intraoperatively, pancreatic
texture was assessed by an operating surgeon of more than 25 years experience. Other
details such as blood loss, duration of surgery, and the procedure done were also
recorded. Pancreas-specific complications like POPF, delayed gastric emptying (DGE),
and postpancreatectomy hemorrhage (PPH) were noted based on International Study Group
of Pancreatic Surgery (ISGPS) definitions and guidelines.[10]
[11]
[12] The morbidity grading was done according to Clavien Dindo grading.[13]
Fig. 1 The calculation of CT attenuation index. (A, B, and D) Hounsfield unit (HU) of pancreas in plain phase. (C) HU of spleen in plain phase. *Red line denoted the line of transection (PAI) was
calculated by utilizing the same technique of Kim et al.[9] CT, computed tomography; P, mean pancreatic attenuation; PAI, pancreatic attenuation
index; S, mean splenic attenuation. P-S and P/S are the pancreatic CT attenuation
indices.
Fig. 2 Fat lobules in low power.
Fig. 3 Confirmation of the fat in high power.
Fig. 4 Calculation of fat-filled area using Adobe photoshop CS.[6]
Statistical Analysis
Data was entered into Microsoft Excel (Microsoft Inc. Redmond, United States) and
analyzed using SPSS 27(IBM Inc. Endicott, New York, United States). Quantitative variables
were summarized as mean and standard deviation. Qualitative variables were summarized
as proportions. The normality of continuous data was assessed by the Kolmogorov–Smirnov
test. Spearman correlation coefficient(ρ) was used to assess the correlation between
PAI with POPF as well as pancreatic texture and 95% confidence intervals were calculated.
Receiver operating characteristic (ROC) curve was plotted for PAI with pancreatic
texture and POPF. ROC curves were plotted for pancreatic fat content with pancreatic
texture and POPF. Cutoff values were calculated on the basis of the maximum values
of the Youden index, calculated by [sensitivity + specificity – 1]. Chi-squared test
was used to study the association between categorical values. p-Value less than 0.05 was considered significant.
Results
Seventy patients underwent pancreatic resections during the study period, out of which
11 were excluded (Chronic Calcific Pancreatitis, CCP: 7, enucleation: 1, and inadequate
normal pancreas in specimen: 3). The age group ranged from 19 to 77 years with a mean
age of 49.4. The demographic details are detailed in [Table 1].
Table 1
Demographic characteristics
|
n = 59
|
|
Age
|
19–77 (mean: 49.44)
|
|
Gender: M/F
|
30/ 29
|
|
Diagnosis
|
|
Ampullary CA
|
15 (25%)
|
|
CA duodenum
|
12 (20%)
|
|
Cystic neoplasm
|
13 (22%)
|
|
Neuroendocrine tumor
|
9 (15%)
|
|
PDAC
|
7 (11.9%)
|
|
Others[a]
|
3 (5%)
|
|
Preoperative diabetes mellitus (yes/no)
|
30 / 29
|
|
BMI (kg/m2)
|
18.1–31 (23.97)
|
|
PAI P-S
|
−23 to 19 (mean: −6.72/SD: 7.856)
|
|
PAI P/S
|
0.54–1.5 (mean: 0.8473/SD: 0.157)
|
|
Pancreatic fat percentage
|
0.4–42 (mean: 9.5076/SD: 9.19520)
|
|
Procedure: PPPD/PD/DP/MVR/DPS +PPPD
|
26/12/17/2/2
|
|
Pancreatic texture judged (firm/soft)
|
34 (soft)/25 (firm)
|
|
Duration of surgery
|
364–580(mean: 421/SD: 101.3)
|
|
Intraoperative blood loss (mL)
|
50–550 mL (191 mL)
|
Abbreviations: CA, carcinoma; MVR, multivisceral resection; P, mean pancreatic attenuation;
PAI, pancreatic attenuation index; PDAC, pancreatic ductal adenocarcinoma; PPPD, pylorus
preserving pancreaticoduodenectomy; S, mean splenic attenuation; SD, standard deviation.
a Others account for diagnosis like benign etiology and low-grade or high-grade dysplasia.
Note: The details of postoperative morbidity are listed in [Table 2].
Table 2
Postoperative complications
|
Postoperative complications
|
Incidence
n = 59
|
|
DGE
|
33
|
|
POPF (B/C)
|
13
|
|
PPH
|
3
|
|
GJ/DJ leak
|
0
|
|
Bile leak
|
2
|
|
Intra-abdominal collection requiring drainage
|
6
|
|
SSI
|
12
|
|
Relaparotomy
|
2
|
|
Portal vein thrombosis
|
0
|
|
Renal failure
|
1
|
|
Hepatic dysfunction
|
1
|
|
Autonomic dysfunction
|
1
|
|
Myocardial infarction
|
1
|
|
Postoperative pancreatitis
|
3
|
|
Clostridium difficile colitis
|
1
|
|
90-day mortality
|
2
|
Abbreviations: CI, confidence interval; DGE, delayed gastric emptying; DJ, duodenojejunostomy;
GJ, gastrojejunostomy; P, mean pancreatic attenuation; PAI, pancreatic attenuation
index; POPF, postoperative pancreatic fistula; PPH, postpancreatectomy hemorrhage;
S, mean splenic attenuation; SSI, surgical site infection.
The P-S ranged from −23 to19 (mean: −6.72/standard deviation [SD]: 7.856) and P/S
ranged 0.54 to 1.5 (mean: 0.8473/SD: 0.157). Pancreatic fat content ranged from 0.4
to 42% (mean: 9.5076 /SD: 9.19520). PAI and fat percentage showed a non-normal distribution
pattern. Intraoperative palpation revealed soft pancreas in 35 and firm pancreas in
24 patients.
The Spearman correlation study showed a significant correlation of PAI (P-S and P/S)
with pancreatic fat, ρ: −0.743 (95% CI: 0.919 to 0.583) (p=0.02) for P-S and 0.775
(95% CI: 0.896 to 0.467 (p=0.001) for P/S ([Fig. 7]). This was in similar to that of the pilot study by Kim et al9 that had ρ-Value
of 0.622 for P-S and 0.616 for P/S.
PAI and POPF did not show a statistically significant relationship on assessment by
Mann–Whitney U test. A statistically significant association was not seen with DGE
and PPH. Preoperative factors like diabetic status, BMI, or the pathology of the tumor
did not show any statistical significance with POPF in our study. A multivariate logistic
regression analysis was done for identifying factors contributing to POPF. However,
no statistically significant association could be demonstrated.
Thirty-five patients had soft pancreas and 24 had firm pancreas. A statistically significant
association was seen between P-S and P/S with pancreatic texture. A ROC was plotted
for PAI with pancreatic texture ([Fig. 6A]). The area under the curve (AUC) are 0.775 (p-value =0.023) and 0.786 (p-value =0.012), respectively. The cut-off value obtained for P-S for predicting pancreatic
texture was 4.65; it was having 74% sensitivity and 80% specificity in predicting
the texture of pancreas. Likewise, a P/S value of 0.89 has a sensitivity of 80% and
specificity 60%.
Fig. 5 Inclusion flowchart.
The pancreatic fat content showed an association with POPF (p = 0.038). An ROC was plotted with pancreatic fat content in X axis and POPF in Y
axis ([Fig. 6B]). The AUC was 0.657. A cutoff value of 6.2% for pancreatic fat content showed 69%
sensitivity and 59% specificity identifying clinically significant POPF. The pancreatic
fat content also showed a statistically significant association with texture of pancreas
(p = 0.004).
Fig. 6 (A) Receiver operating characteristic (ROC) curve plotted for pancreatic attenuation
index (PAI) and pancreatic texture. (B) ROC curve plotted for pancreatic fat and postoperative pancreatic fistula. P, mean
pancreatic attenuation; S, mean splenic attenuation.
Fig. 7 Scatterplots and regression lines showing correlations between pancreatic fat fraction
and PAI. (A) P-S = −0.743. (B) P/S = −0.775. P, mean pancreatic attenuation; PAI, pancreatic attenuation index;
S, mean splenic attenuation.
Discussion
This study showed a strong correlation between PAI with pancreatic fat content. The
ρ-value obtained in our study for PAI (P-S and P/S were –0.743 and –0.775, respectively)
shows a better correlation compared with the study by Kim et al that had ρ-value of
–0.622 for P-S and –0.616 for P/S(9). Gnanasekaran et al used PAI and pancreatic enhancement
ratio (PER) in predicting POPF. PER is a marker of pancreatic fibrosis. In their study,
PAI did not show any association with pancreatic fat or POPF, while PER was found
to be helpful in predicting POPF.[14] Kusafuka et al used pancreatic–visceral CT attenuation ratio and a value of more
than 0.40 was significant risk factor of POPF. Both studies quoted before assumed
that lower pancreatic CT attenuation denotes a fatty pancreas. In contrast, the study
by Ohgi et al found that higher pancreatic attenuation was seen in cases of POPF.[15] The precision of CT-guided risk calculation of pancreas may be improved by using
other imaging modalities like ultrasound shear wave elastography (USWE) and MRI. Sushma
et al noted that USWE values are lower in patients who had POPF and may help in predicting
soft pancreas.[16] Many studies have shown the value of MRI in the assessment of pancreatic fibrosis
that indirectly indicates a firm pancreas.[17] Our study observed a significant association for PAI and fat content with pancreatic
texture and we were able to derive cutoff values for the prediction of the same. In
our study, pancreatic fat content showed association with POPF (p-value = 0.038). A meta-analysis by Zhou et al also showed that high pancreatic fat
content can lead to POPF.[18] Hence, a preoperative identification of a fatty pancreas may act as a surrogate
marker of a soft pancreas that is a strong risk factor for POPF.
POPF has multiple risk factors, either modifiable or nonmodifiable. Fistula risk score
put forward small duct diameter, soft pancreas, high-risk pathology (ampullary, duodenal,
and islet cell neoplasms), and excessive blood loss as high-risk factors.[19] Postoperative pancreatitis can also lead to POPF. We had three patients with postoperative
pancreatitis in the immediate postoperative period and all three developed a grade
B/C POPF. High pancreatic fat content is a strong risk factor for acute pancreatitis.
Surgical procedures have always shown a relationship with POPF. The chance of POPF
in literature was 13% in pancreaticoduodenectomy (PD), 29% in DP, and 41% in central
pancreatectomy.[20]
[21] In our study, we had 18% in PD, 35% in DP, and 100% in combined PD with distal pancreaticosplenectomy
(DPS).
High pancreatic fat content can lead to higher insulin resistance and may lead to
new onset DM or worsening of DM following resection. Kanwat et al noted that patients
with POPF had more incidence of endocrine insufficiency after Whipple procedure.[22] Kim et al also showed that low PAI is associated with impaired glucose metabolism.
In our study, we could not get any statistically significant relationship of preoperative
diabetic status with PAI or POPF. Lifestyle modifications and weight reduction may
improve pancreatic steatosis thereby improving the risk profile; hence, there may
be an option for delaying surgeries in relatively benign pancreatic pathologies if
the PAI is not favorable.
Early detection of high-risk cases will help in planning which patients could be taken
up for an enhanced recovery after surgery (ERAS) protocol[23] or an intensive follow-up in postoperative period. POPF can be an inciting event
for PPH. During the event of a pancreatic fistula, the leaked pancreatic enzymes can
result in pseudoaneurysm formation due to its proteolytic activity on the arteries
in the surgical bed like GDA, splenic artery ,hepatic artery etc and result in PPH.[24]
There is some evidence to show that somatostatin analogues and steroid may be useful
in reduction of POPF. Our unit routinely gives 100 µg of octreotide subcutaneously
prior to pancreatic transection in high-risk cases that is then continued for the
next 5 days and tapered based on the drain fluid amylase value. Many randomized controlled
trial have identified that there is a role for steroid administration in the reduction
of POPF.[25] Preoperatively identified high-risk cases can thus undergo pharmacological prophylaxis
thereby reducing the chances of POPF.
Limitation
The risk factors for postpancreatectomy outcomes are multifactorial, and for the assessment
of individual factors a larger sample size is required. We were not able to validate
PAI as a preoperative risk predictor because of the same. We could not assess the
interobserver variation in assessment of the CT images due to the lack of resources
during the coronavirus disease 2019 pandemic. Even with all the resource constraints
,we were able to shed some light in identifying a preoperative tool in the prediction
of POPF and pancreatic fat content.
Conclusion
PAI seems to be useful tool in predicting the pancreatic fat content. This may help
the surgeon in identifying a high-risk pancreas preoperatively, and in turn help modify
the perioperative treatment protocols.
