CT-FRS for POPF
Description
In this multicenter retrospective analysis, we focused on with pancreatoduodenectomy performed at four institutions. This study was to develop a modified Fistula Risk Score (FRS) for predicting clinically relevant postoperative pancreatic fistulas (CR-POPFs) after pancreatoduodenectomy (PD) based on both FRS and contrast-enhanced computed tomography (CE-CT). This was a multicenter, multicohort retrospective study involving 990 consecutive patients from four high-volume academic institutions between 2009 and 2019. The enhanced CT-FRS model initially targeted 26 pre- and intraoperative factors, including CT descriptors, FRS elements and clinical factors for predicting CR-POPF events in discovery (n=718) and externally validated (n=272) datasets. All patients underwent preoperative multiphasic scans within 4 weeks of surgery with at least two contrast-enhanced phases and one non-enhanced phase, as stipulated by current National Comprehensive Cancer Network (NCCN) guidelines. CT descriptors, including four scores of semantic features and seven measurements are detailed in the information list, including scoring of all features by CT, visceral fat area (VFA), pancreatic thickness, width, stump area, remnant pancreatic volume [RPV], surface area-to-volume [Sa/V] ratio, and mean attenuation at pancreatic phase. Scored semantic features were CT-based fatty change (0-3), pancreatic inflammation (0-3), degree of pancreatic atrophy (0-3), and MPD (0-4). All pancreaticoenteric reconstructions were performed after PDs in conjunction with either pancreaticojejunostomy (PJ) or pancreaticogastrostomy (PG) for a full array of indications. Both in discovery and validation datasets, qualifying patients underwent preoperative standardized pancreatic CE-CT imaging, which documented of all four FRS elements. Medical records were accessed for demographic and clinical parameters, including age, sex, BMI, diabetes mellitus, jaundice, smoking, alcohol abuse, and operative factors. Grading of POPFs was dictated by definitions of the International Study Group of Pancreatic Fistula (ISGPF) updated in 2016. The four risk factors required for FRS determinations, operative time and type of anastomosis were obtained from operative notes. Through intraoperative palpation, experienced lead surgeons subjectively characterized pancreatic texture as soft or firm, regardless of histopathology. MPD size (mm) was assessed in axial images of the most recent preoperative CT scans or evaluated intraoperatively by placing flexible rulers against cut surfaces of transected pancreas. The strategies of fistula mitigation were based on surgeons' preferences.