Elsevier

Pancreatology

Volume 20, Issue 5, July 2020, Pages 867-874
Pancreatology

Three-dimensional remnant pancreatic volume ratio indicates postoperative pancreatic exocrine insufficiency in pancreatic cancer patients after distal pancreatectomy

https://doi.org/10.1016/j.pan.2020.06.018Get rights and content

Abstract

Background

Pancreatectomy may cause serious pancreatic exocrine insufficiency (PEI), which can lead to some nutritional problems, including new-onset diabetes mellitus (DM) or non-alcoholic fatty liver disease (NAFLD). Recent studies have reported that remnant pancreatic volume (RPV) significantly influences postoperative PEI. However, the specific correlation between RPV and postoperative PEI remains unclear. Here, we compare various pre-, peri-, and postoperative risk factors in a retrospective cohort to address whether preoperatively measured RPV is a predictor of postoperative PEI in pancreatic cancer patients after distal pancreatectomy (DP).

Methods

Sixty-one pancreatic cancer patients who underwent DP were retrospectively enrolled. Pancreatic volume was measured using preoperative 3D images, which simulated the actual intraoperative pancreatic parenchymal volume. We obtained the 3D-measured RPV and resected pancreatic volume. We calculated the ratio of the RPV to the total pancreatic volume and then divided the cohort into high- and low-RPV ratio groups based on a cut-off value (>0.35, n = 37 and ≤ 0.35, n = 24). Using multivariate analysis, the RPV ratio as well as pre-, peri- and postoperative PEI risk factors were independently assessed.

Results

The multivariate analysis revealed that a low RPV ratio (odds ratio [OR], 5.911; p = 0.001), a hard pancreatic texture (OR, 3.313; p = 0.023) and TNM stage III/IV (OR, 3.515; p = 0.031) were strong predictors of the incidence of PEI.

Conclusions

The present study indicates that the RPV ratio is an additional useful predictor of postoperative nutrition status in pancreatic cancer patients.

Introduction

Pancreatectomy remains the foundation of curative surgical treatments for pancreatic cancer. Recent improvements in operative techniques and perioperative management have substantially decreased postoperative mortality rates to lower than 5% [1,2]. Therefore, the focus has shifted to the crucial maintenance of postoperative quality of life, including nutritional status. Pancreatectomy may cause serious pancreatic exocrine insufficiency (PEI), which can lead to nutritional problems, including new-onset diabetes mellitus (DM) or non-alcoholic fatty liver disease (NAFLD) [[3], [4], [5]].

A variety of predictive factors have been identified and applied to determine the risk of postoperative PEI in pancreatic cancer patients. The reported predictors include pre-, peri-, and postoperative risk factors, such as high body mass index (BMI), hard pancreatic texture, postoperative pancreatic duct dilatation and postoperative pancreatic fistula (POPF) [[6], [7], [8]].

Among these predictive factors, recent studies have reported that remnant pancreatic volume (RPV) also significantly influences postoperative PEI [[9], [10], [11]]. Iizawa et al. revealed that patients whose pancreas cut line was made at the left side of the superior mesenteric artery (SMA) were highly likely to develop postoperative NAFLD due to the disruption of exocrine function [10].

However, these correlations with RPV and postoperative PEI remain controversial. First, pancreatic volume has been reported to be associated with individual body surface area [12]. Second, RPV has been evaluated during the postoperative period. Third, atrophic changes in the remnant pancreatic texture are often attributed to obstructive pancreatitis induced by advanced pancreatic head cancer. Therefore, with regard for patients who undergo pancreaticoduodenectomy (PD), the correlation between RPV and postoperative PEI remains unclear.

We originally performed preoperative three-dimensional (3D) surgical simulations of pancreatic surgeries and used these to measure pancreatic volume [[13], [14], [15]]. In this study, we compared various pre-, peri-, and postoperative risk factors in a retrospective cohort to address whether preoperatively measured RPV is a predictor of postoperative PEI in pancreatic cancer patients after distal pancreatectomy (DP). To the best of our knowledge, this is the first report to identify a correlation between the preoperative RPV and postoperative PEI in resected pancreatic cancer patients.

Section snippets

Patients

We retrospectively evaluated 68 consecutive pancreatic cancer patients who underwent DP at Tsukuba Medical Center Hospital, Tsukuba, Japan, between January 2005 and December 2019. First, we excluded 7 patients, including 3 with preoperative adjuvant treatment and 4 who underwent surgeries that were more extensive than the standard DP procedure, such as simultaneous gastrectomy or colectomy. The final cohort included 61 patients with pancreatic ductal adenocarcinoma who underwent DP. The ethics

Patient characteristics

In the present cohort, we observed that the RPV ratio showed a normal distribution. The mean RPV ratio was 0.41 ± 0.13 (range, 0.24–0.68). The cut-off value was 0.35 for the RPV ratio (sensitivity and specificity: 88.7% and 79.7%, respectively). The area under the concentration-time curve (AUC) was 0.885. We divided the cohort into high- and low-RPV ratio groups based on the obtained cut-off value (>0.35, n = 37 and ≤ 0.35, n = 24, respectively). The characteristics of the patients in the low-

Discussion

In this study, we found that the preoperative 3D-measured RPV ratio, hard pancreatic texture, and TNM stage III/IV were strong predictors of postoperative PEI in pancreatic cancer patients after DP. Therefore, we believe that the RPV ratio has additional value as a predictor of postoperative nutrition status in pancreatic cancer patients.

The mechanisms by which low RPV values potentially contribute to postoperative PEI remain unknown. One potential hypothesis proposes that in patients with a

Grant support

None.

Declaration of competing interest

The authors declare no conflict of interest or source of funding.

Acknowledgments

We have no acknowledgments.

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