title: Preoperative CT scan helps to predict the occurrence of severe pancreatic fistula after pancreaticoduodenectomy.
abstract: 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/m (P = 0.02), retro-renal fat thickness over 15 mm (P = 0.006), TFA over the median (>233 cm; P = 0.023), and VFA over the median (>84 cm; P < 0.0001) were significantly associated with an increased risk of symptomatic PF (grade B and C). In multivariate analysis, VFA greater than 84 cm (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 cm 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.
authors.affiliation: Department of Hepato-Pancreato-Biliary Surgery--Pôle des Maladies de l'Appareil Digestif (PMAD), AP-HP, Beaujon Hospital, Clichy, France.
authors.forename: Hadrien
authors.initials: H
authors.lastname: Tranchart
authors.forename: Sébastien
authors.initials: S
authors.lastname: Gaujoux
authors.forename: Vinciane
authors.initials: V
authors.lastname: Rebours
authors.forename: Marie-Pierre
authors.initials: MP
authors.lastname: Vullierme
authors.forename: Safi
authors.initials: S
authors.lastname: Dokmak
authors.forename: Philippe
authors.initials: P
authors.lastname: Levy
authors.forename: Anne
authors.initials: A
authors.lastname: Couvelard
authors.forename: Jacques
authors.initials: J
authors.lastname: Belghiti
authors.forename: Alain
authors.initials: A
authors.lastname: Sauvanet
mesh_terms: D050153:Abdominal Fat / Q000000981:diagnostic imaging*; D000230:Adenocarcinoma / Q000601:surgery; D000368:Aged; D002291:Carcinoma, Papillary / Q000601:surgery; D005260:Female; D006801:Humans; D050152:Intra-Abdominal Fat / Q000000981:diagnostic imaging; D008099:Liver / Q000000981:diagnostic imaging; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D010179:Pancreas / Q000000981:diagnostic imaging; D010185:Pancreatic Fistula / Q000000981:diagnostic imaging / Q000453:epidemiology*; D010190:Pancreatic Neoplasms / Q000601:surgery; D016577:Pancreaticoduodenectomy; D011183:Postoperative Complications / Q000453:epidemiology; D057234:Preoperative Period; D012307:Risk Factors; D013154:Spleen / Q000000981:diagnostic imaging; D050507:Subcutaneous Fat, Abdominal / Q000000981:diagnostic imaging; D014057:Tomography, X-Ray Computed