Preoperative CT Scan Helps to Predict the Occurrence of Severe Pancreatic Fistula After Pancreaticoduodenectomy

In Brief Objective: To assess the influence of body fat distribution, estimated by a preoperative computed tomographic (CT) scan, on pancreatic fistula (PF) risk after pancreaticoduodenectomy (PD). Background: Pancreatic fatty infiltration is a predictive factor of PF, but accurate preoperative assessment is challenging. We hypothesized that it could be associated with an increased visceral obesity and could be assessed preoperatively. Methods: Over 18 months, 103 consecutive patients with PD and pancreaticogastrostomy were studied. Demographic, radiologic, and pathologic data were correlated to PF occurrence. Radiologic data included on a nonenhanced CT acquisition: pancreas, spleen, and liver density measures (Dpancreas, Dspleen, and Dliver [densities of the pancreas, spleen, and liver in hounsfield units], respectively), retro-renal fat thickness, and at the level of the umbilicus, total, visceral, and subcutaneous fat area (TFA [total fat area], VFA [visceral fat area], and SFA [subcutaneous fat area], respectively). Pancreatic fatty infiltration was graded histologically. Logistic regression analysis was used to identify independent predictors of PF-graded B and C according to the International Study Group on the Pancreatic Fistula. Results: Among the 103 patients, 37% (n = 38) developed a PF (47.4% grade A, 39.5% grade B, and 13.1% grade C). PF risk was correlated with pancreatic fatty infiltration (P = 0.017). In univariate analysis, male gender (P = 0.023), body mass index (BMI) over 25 kg/m2 (P = 0.02), retro-renal fat thickness over 15 mm (P = 0.006), TFA over the median (>233 cm2; P = 0.023), and VFA over the median (>84 cm2; P < 0.0001) were significantly associated with an increased risk of symptomatic PF (grade B and C). In multivariate analysis, VFA greater than 84 cm2 (OR = 8.16, P = 0.002) was the only independent predictive factor of grade B or C PF. Using the same model, a VFA greater than 84 cm2 was the only independent factor associated with the presence of fatty pancreas on pathologic examination. Conclusions: Preoperative assessment of body fat distribution by a CT scan, as a surrogate for fatty pancreas infiltration, can help to predict the occurrence of clinically significant PF after PD. Pancreatic fatty infiltration is a predictive factor of pancreatic fistula but is only assessable postoperatively on pathologic examination. On the opposite, body fat distribution is easily estimated by preoperative computed tomographic (CT) scan. In this article, we have shown that Visceral Fat Area, preoperatively measured on CT scan, as a surrogate for fatty pancreas infiltration, is an independent preoperative predictive factor of clinically significant (grade B and C) pancreatic fistula after pancreaticoduodenectomy.