Dual-Energy CT for Risk of Postoperative Pancreatic Fistula

HomeRadiologyVol. 304, No. 1 PreviousNext Reviews and CommentaryFree AccessEditorialDual-Energy CT for Risk of Postoperative Pancreatic FistulaJeong Min Lee , Jeong Hee YoonJeong Min Lee , Jeong Hee YoonAuthor AffiliationsFrom the Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea (J.M.L., J.H.Y.); and Department of Radiology, Seoul National University College of Medicine, Seoul, Korea (J.M.L.).Address correspondence to J.M.L. (e-mail: [email protected]).Jeong Min Lee Jeong Hee YoonPublished Online:Mar 22 2022https://doi.org/10.1148/radiol.220320MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In See also the article by Shi and Lu et al in this issue.Jeong Min Lee is a professor in the Radiology Department at Seoul National University Hospital. He has published more than 470 articles and is on the Radiology, Korean Journal of Radiology, Cancer Imaging, and Liver Cancer editorial boards. He was named an honorary fellow of ESGAR and an ISMRM Fellow of the Society in 2020 and received the Bushi Medical Award in 2021. He is a formal member of The Korean Academy of Science and Technology and the National Academy of Medicine of Korea. He is president of the Korean Society of Radiology and has served as chair of the educational committee for the Korean Society of Magnetic Resonance in Medicine. His main scientific interests include MRI diagnosis of hepatobiliary and pancreatic diseases, multiparametric MRI for oncologic diseases, MR elastography, dual-energy CT for abdominal diseases, and image-guided tumor ablation.Download as PowerPointOpen in Image Viewer Dr Jeong Hee Yoon is an associate professor of radiology at Seoul National University Hospital and Seoul National University College of Medicine. Her research interests are in abdominal CT and MRI, with an emphasis on hepatobiliary pancreas imaging and oncologic imaging. Dr Yoon serves on the Journal of Magnetic Resonance Imaging editorial board.Download as PowerPointOpen in Image Viewer Postoperative pancreatic fistula (POPF) is the major determinant of morbidity and mortality after pancreatic resection (1,2). Despite recent advances in surgical techniques to prevent POPF, 7%–21% of pancreatic surgical proceduresfor POPF are performed at high-volume centers (2,3). The most serious morbidity and complications of POPF include hemorrhage and sepsis, either of which may result in multiorgan failure and death (4). Therefore, accurate preoperative prediction of risk of POPF is crucial, as it can allow surgeons to selectively use preventive measures and tailor their perioperative management (5,6).Several previous studies revealed that morphologic features, such as pancreatic thickness, main pancreatic duct diameter, and pancreatic parenchymal changes, including steatosis and fibrosis, were associated with a higher risk of developing POPFs (1,6). Recent studies also showed that intravoxel incoherent motion diffusion-weighted imaging or pancreatic stiffness at MR elastography or US elastography could be used to evaluate pancreatic parenchymal fibrosis and MRI proton density fat fraction for steatosis (6–8). However, those MRI quantitative tools are either expensive or have limited accessibility, and US elastography has an issue of reproducibility (9). Thus, there is still an unmet clinical need for reproducible and straightforward measurement tools for preoperative identification of patients at high risk for POPF.In this issue of Radiology, Shi and Lu et al (9) report the results of a retrospective study evaluating whether multiphasic dual-energy CT (DECT)-derived iodine concentration (IC) and fat fraction can improve the prediction of POPF risks compared with contrast-enhanced CT attenuation values in 107 patients who underwent pancreatoduodenectomy and DECT. Their results showed that the pancreatic parenchymal–to–portal venous phase IC ratio was an independent predictor of POPF occurrence and negatively correlated with histologic fibrosis (ρ = -0.53, P < .001). This may be because fibrotic areas have gradual contrast material accumulation. In addition, the accuracy of the pancreatic parenchymal–to–venous phase IC ratio in the prediction of POPF was higher than that of the CT value ratio in the same phases. Because pancreatic parenchyma may contain both fibrosis and fat simultaneously in patients with pancreatic cancer, IC ratio may represent the iodine component in fibrosis more accurately than CT attenuation values (10).Of note, pancreatic fat fraction determined with DECT was not associated with POPF, which is consistent with the literature (6). Theoretically, fibrotic areas have gradual contrast material accumulation and may have higher IC during a delayed phase than during a venous phase. However, in the current study, the delayed phase IC at 3 minutes and the pancreatic parenchymal–to–delayed phase IC ratio were not significant factors for POPF. Therefore, further investigation should be warranted regarding the value of the pancreatic parenchymal–to–delayed phase IC ratio at 5 minutes in the prediction of POPF. Nonetheless, on the basis of study results, IC ratio derived from preoperative DECT is a promising method with which to predict the occurrence of POPF after pancreatoduodenectomy.The work by Shi and Lu et al (9) is important because CT is the most used imaging modality in pre- and perioperative periods in patients who will undergo pancreatic surgery. Therefore, we firmly believe that the current study results of iodine concentration ratio derived from DECT data to predict POPF must be appealing for pancreatic surgeons to tailor their perioperative management. Limitations of this study include a single-center retrospective study having potential selection and institutional biases; use of one anastomosis technique, which may affect the incidence of POPF; and a contrast material injection method (body weight–adjusted iodine dose determination with fixed injection rates), which could be a confounder of pancreatic parenchymal enhancement. Despite these limitations, we believe that preoperative identification of patients at high risk for POPF using DECT will be useful for improving the care of patients undergoing pancreatectomy.Disclosures of conflicts of interest: J.M.L. Radiology editorial board member. J.H.Y. Honoraria from Bayer.References1. Kamarajah SK, Bundred JR, Lin A, et al. Systematic review and meta-analysis of factors associated with post-operative pancreatic fistula following pancreatoduodenectomy. ANZ J Surg 2021;91(5):810–821. Crossref, Medline, Google Scholar2. Bassi C, Marchegiani G, Dervenis C, et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery 2017;161(3):584–591. Crossref, Medline, Google Scholar3. Byun Y, Choi YJ, Han Y, et al. Outcomes of 5000 pancreatectomies in Korean single referral center and literature reviews. J Hepatobiliary Pancreat Sci 2021. 10.1002/jhbp.933. Published online February 26, 2021. Crossref, Google Scholar4. Nahm CB, Connor SJ, Samra JS, Mittal A. Postoperative pancreatic fistula: a review of traditional and emerging concepts. Clin Exp Gastroenterol 2018;11:105–118. Crossref, Medline, Google Scholar5. Nakata K, Mori Y, Ikenaga N, et al. Management of postoperative pancreatic fistula after pancreatoduodenectomy: Analysis of 600 cases of pancreatoduodenectomy patients over a 10-year period at a single institution. Surgery 2021;169(6):1446–1453. Crossref, Medline, Google Scholar6. Yoon JH, Lee JM, Lee KB, et al. Pancreatic Steatosis and Fibrosis: Quantitative Assessment with Preoperative Multiparametric MR Imaging. Radiology 2016;279(1):140–150. Link, Google Scholar7. Shi Y, Liu Y, Gao F, et al. Pancreatic Stiffness Quantified with MR Elastography: Relationship to Postoperative Pancreatic Fistula after Pancreaticoenteric Anastomosis. Radiology 2018;288(2):476–484. Link, Google Scholar8. Marasco G, Ricci C, Buttitta F, et al. Is Ultrasound Elastography Useful in Predicting Clinically Relevant Pancreatic Fistula After Pancreatic Resection?: A Systematic Review and Meta-analysis. Pancreas 2020;49(10):1342–1347. Crossref, Medline, Google Scholar9. Shi HY, Lu ZP, Li MN, Ge YQ, Jiang KR, Xu Q. Dual-Energy CT Iodine Concentration to Evaluate Postoperative Pancreatic Fistula after Pancreatoduodenectomy. Radiology 2022;304(1):65–72. Link, Google Scholar10. Yoon JH, Lee JM, Kim JH, et al. Hepatic fibrosis grading with extracellular volume fraction from iodine mapping in spectral liver CT. Eur J Radiol 2021;137:109604. Crossref, Medline, Google ScholarArticle HistoryReceived: Feb 10 2022Revision requested: Feb 22 2022Revision received: Feb 22 2022Accepted: Feb 24 2022Published online: Mar 22 2022Published in print: July 2022 FiguresReferencesRelatedDetailsAccompanying This ArticleDual-Energy CT Iodine Concentration to Evaluate Postoperative Pancreatic Fistula after PancreatoduodenectomyMar 22 2022RadiologyRecommended Articles Dual-Energy CT Iodine Concentration to Evaluate Postoperative Pancreatic Fistula after PancreatoduodenectomyRadiology2022Volume: 304Issue: 1pp. 65-72Pancreatic Stiffness Quantified with MR Elastography: Relationship to Postoperative Pancreatic Fistula after Pancreaticoenteric AnastomosisRadiology2018Volume: 288Issue: 2pp. 476-484Noninvasive Staging of Liver Fibrosis with Dual-Energy CT: Close but No CigarRadiology2021Volume: 298Issue: 3pp. 609-610Noninvasive Staging of Liver Fibrosis Using 5-Minute Delayed Dual-Energy CT: Comparison with US Elastography and Correlation with Histologic FindingsRadiology2021Volume: 298Issue: 3pp. 600-608Chronic Pancreatitis or Pancreatic Tumor? A Problem-solving ApproachRadioGraphics2019Volume: 39Issue: 7pp. 1965-1982See More RSNA Education Exhibits Multi-Modality Imaging of Pancreatic TraumaDigital Posters2019Pancreatic Injury: Multimodality Imaging and Updated Review of ManagementDigital Posters2019Pancreatic Cancer: Early Detection, Diagnosis and StagingDigital Posters2020 RSNA Case Collection Pancreatic lacerationRSNA Case Collection2020Groove PancreatitisRSNA Case Collection2021Autoimmune PancreatitisRSNA Case Collection2021 Vol. 304, No. 1 Metrics Altmetric Score PDF download