Differentiated Surgical Prevention of Postoperative Pancreatic Fistula Following Pancreatoduodenectomy Based on Preoperative Computed Tomography Assessment of the Pancreas
DOI:
https://doi.org/10.11603/2414-4533.2026.3.16490Keywords:
Computed Tomography, Risk Stratification, Prognostic Models, Morphometry, Tissue Density, Drainage, Somatostatin Analogues, Perioperative CareAbstract
The aim of the work: to evaluate the effectiveness of a risk-adapted prophylactic strategy based on preoperative computed tomography (CT) assessment in reducing the incidence of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreatoduodenectomy.
Materials and Methods. A retrospective–prospective cohort study involving 200 patients who underwent pancreatoduodenectomy was performed. The retrospective control cohort included 106 patients managed according to a standard perioperative protocol. The prospective study cohort comprised 94 patients who underwent preoperative risk stratification using a 6-point CT-based score incorporating pancreatic parenchymal density, main pancreatic duct diameter, duct-to-parenchyma ratios in two planes, and body mass index. Preventive interventions were selected according to the calculated risk category. The primary endpoint was CR-POPF grade B/C according to the 2016 International Study Group of Pancreatic Surgery (ISGPS) definition. Secondary endpoints included grade C pancreatic fistula, delayed gastric emptying, post-pancreatectomy hemorrhage, relaparotomy, length of hospital stay, and postoperative mortality.
Results. Patients in the study cohort demonstrated a significantly less favorable pancreatic morphology than controls, including lower pancreatic density (27.7 vs. 35.4 HU; p<0.001) and a higher prevalence of soft pancreatic texture (78.7 vs. 58.5 %; p=0.004). Despite this, the incidence of CR-POPF decreased from 21.7 to 12.8 % (relative risk 0.59; p=0.135). In the predefined high-risk subgroup (score ≥4; n=109), CR-POPF occurred in 16.9 % of study patients compared with 43.2 % of controls (OR=0.268; 95 % CI=0.111–0.647; p=0.004). Grade C fistula was significantly less frequent in the study cohort (1.1 vs. 7.5 %; p=0.028). Delayed gastric emptying occurred less often (5.3 vs. 18.9 %; p=0.005), while median hospital stay decreased from 16.5 to 13.0 days (p=0.0005). These findings suggest that CT-based preoperative risk stratification enables individualized preventive management after pancreatoduodenectomy and may improve postoperative outcomes even in patients with unfavorable pancreatic morphology.
Conclusions. A risk-adapted prophylactic protocol guided by preoperative CT characteristics is associated with a reduced incidence of clinically relevant postoperative pancreatic fistula, severe grade C fistula, delayed gastric emptying, and shorter hospitalization after pancreatoduodenectomy. Further validation in randomized controlled trials is warranted.
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