Three-dimensional remnant pancreatic volume ratio indicates postoperative pancreatic exocrine insufficiency in pancreatic cancer patients after distal pancreatectomy
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.
References (34)
- et al.
Predictive factors for change of diabetes mellitus status after pancreatectomy in preoperative diabetic and nondiabetic patients
J Gastrointest Surg
(2014) - et al.
Remnant pancreatic parenchymal volume predicts postoperative pancreatic exocrine insufficiency after pancreatectomy
Surgery
(2016) - et al.
Long-term outcomes after pancreaticoduodenectomy using pair-watch suturing technique: different roles of pancreatic duct dilatation and remnant pancreatic volume for the development of pancreatic endocrine and exocrine dysfunction
Pancreatology
(2017) - et al.
Remnant pancreatic volume as an indicator of poor prognosis in pancreatic cancer patients after resection
Pancreatology
(2019) - et al.
Intensive insulin therapy prevents the progression of diabetic microvascular complications in Japanese patients with non-insulin-dependent diabetes mellitus: a randomized prospective 6-year study
Diabetes Res Clin Pract
(1995) - et al.
Serum nutritional markers for prediction of pancreatic exocrine insufficiency in chronic pancreatitis
Pancreatology
(2012) - et al.
Postoperative pancreatic fistula: an international study group (ISGPF) definition
Surgery
(2005) - et al.
Correlation between radiographic classification and pathological grade of portal vein wall invasion in pancreatic head cancer
Ann Surg
(2012) - et al.
A prospective randomized trial comparing standard pancreatoduodenectomy with pancreatoduodenectomy with extended lymphadenectomy in resectable pancreatic head adenocarcinoma
Surgery
(2005) - et al.
Clinical characteristics of de novo nonalcoholic fatty liver disease following pancreaticoduodenectomy
J Gastroenterol
(2011)
Risk factors for hepatic steatosis after pancreatectomy: a retrospective observational cohort study of the importance of nutritional management
Pancreas
Randomized prospective trial of the effect of induced hypergastrinemia on the prevention of pancreatic atrophy after pancreatoduodenectomy in humans
Ann Surg
Long-term assessments after pancreaticoduodenectomy with pancreatic duct invagination anastomosis
Surg Today
Early and late complications of pylorus-preserving pancreatoduodenectomy in Japan
J Hepatobiliary Pancreat Surg
Postoperative chemoradiotherapy following pancreaticoduodenectomy. Impact of dose-volumetric parameters on the development of diabetes mellitus
Strahlenther Onkol
Pancreatic volume is one of the independent prognostic factors for resectable pancreatic ductal adenocarcinomas
J Hepatobiliary Pancreat Sci
Three-dimensional simulation of pancreatic surgery showing the size and location of the main pancreatic duct
Surg Today
Cited by (8)
Current status of the diagnosis and treatment of pancreatic exocrine insufficiency after pancreatectomy
2023, Journal of Clinical HepatologyDevelopment of de novo nonalcoholic fatty liver disease following pancreatectomy
2023, Medicine (United States)De novo non-alcoholic fatty liver disease after pancreatectomy: A systematic review
2022, World Journal of Clinical CasesRisk factors for exocrine pancreatic insufficiency after pancreatic surgery: a systematic review and meta-analysis
2022, Canadian Journal of Surgery