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Prediction of Pancreatic Anastomotic Failure After Pancreatoduodenectomy: The Use of Preoperative, Quantitative Computed Tomography to Measure Remnant Pancreatic Volume and Body Composition

Kirihara, Yujiro MD*; Takahashi, Naoki MD; Hashimoto, Yasushi MD*; Sclabas, Guido M. MD*; Khan, Saboor MD*; Moriya, Toshiyuki MD*; Sakagami, Junichi MD; Huebner, Marianne PhD§; Sarr, Michael G. MD*; Farnell, Michael B. MD*

doi: 10.1097/SLA.0b013e31827827d0
Original Articles

Objective: To determine whether remnant pancreatic volume (RPV), subcutaneous/visceral adipose tissue(SAT/VAT) area, and skeletal muscle (SM) area calculated from preoperative computed tomography (CT) can predict the occurrence of pancreatic anastomotic failure (PAF) after pancreatoduodenectomy (PD).

Background: Increased body mass index, small main pancreatic duct, and soft pancreatic texture are well-established predictors of PAF after PD. The impact on PAF of anthropomorphic measurements, such as RPV and body composition, is unknown.

Methods: In 173 patients undergoing PD from 2004 to 2009, cross sections of SAT/VAT/SM area were quantitated volumetrically, respectively, from preoperative CT. RPV was calculated from the CT as the sum of pancreatic tissue area to the left of the presumed pancreatic transection site. The predictive ability for multiple models using combinations of body mass index, RPV, SAT/VAT area, SM area, main pancreatic duct size, and pancreatic gland texture was described using a concordance index (c-index).

Results: Clinically relevant PAF occurred in 22 patients (13%). Multivariate logistic regression analysis identified RPV (P = 0.0012), VAT area (P = 0.0003), and SM area (P = 0.0006) as independent predictors of PAF. Using previously identified risk factors, the best 2-predictor model (body mass index and pancreatic duct size) resulted in a c-index of 0.748. Using anthropomorphic factors, however, the 2-predictor model using VAT and SM areas revealed a superior c-index of 0.959.

Conclusions: Our 2-predictor model using VAT area and SM area based on volumetric quantification using preoperative CT may offer clinical benefit as an objective prognostic measure to predict clinically relevant PAF after PD.

A novel model using measurements of visceral adipose tissue (visceral/pancreatic fat) and loss of skeletal muscle (sarcopenia) by volumetric preoperative pancreatic computed tomography when evaluated retrospectively had value in predicting clinically relevant pancreatic anastomotic failure in patients undergoing pancreatoduodenectomy.

*Division of Gastroenterologic and General Surgery

Department of Radiology

Division of Gastroenterology and Hepatology

§Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN.

Reprints: Michael B. Farnell, MD, Division of Gastroenterologic and General Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905. E-mail:

The authors declare no conflict of interest and there is no external funding

Disclosure: Supported by funding from Mayo Clinic.

Presented as Poster at Society for Surgery of the Alimentary Tract meeting, Chicago, IL, May 8, 2011.

© 2013 Lippincott Williams & Wilkins, Inc.