AJR:193, September 2009 W175
as “drain output of any measurable volume
of fluid on or after postoperative day 3 with
an amylase content greater than three times
the serum amylase activity” [11].
The overall rate of pancreatic fistula after
pancreaticoduodenectomy ranges from 17%
in patients in whom the pancreatic remnant
has a hard consistency [12] and exocrine pan-
creatic function and pancreatic juice output
are impaired [13] to 25% in cases in which
the pancreas is soft [1], that is, the parenchy-
ma is normal [13]. Soft pancreatic texture [1,
3, 13] and small pancreatic duct size [3] are
the most important preoperative risk factors
for the development of pancreatic fistula.
The diagnosis of pancreatic fistula usually
is made an average of 7 days after pancreati-
coduodenectomy [5, 14, 15]. Pancreatic fistula
diagnosed with repeated assays of pancreatic
enzymes in peripancreatic fluid drainage [11,
14, 16] is recognized in only 70–75% of cases
[2, 5, 17]. The peripancreatic drains routinely
Utility of CT in the Diagnosis
of Pancreatic Fistula After
Pancreaticoduodenectomy in
Patients with Soft Pancreas
Onorina Bruno
1,2
Giuseppe Brancatelli
3,4,5
Alain Sauvanet
6
Marie Pierre Vullierme
1,2
Vincent Barrau
1
Valérie Vilgrain
1,2,7
Bruno O, Brancatelli G, Sauvanet A, Vullierme MP,
Barrau V, Vilgrain V
1
Université Paris 7 Denis Diderot, Paris F-75018, France.
2
AP-HP, Department of Radiology, Hôpital Beaujon,
Clichy, France.
3
Department of Radiology, Università di Palermo, Via
Villaermosa 29, Palermo, 90139, Italy. Address
correspondence to G. Brancatelli (gbranca@yahoo.com).
4
University of Pittsburgh School of Medicine, Pittsburgh,
PA.
5
Radiology Unit, La Maddalena Hospital, Palermo, Italy.
6
Service de Chirurgie Digestive, Hôpital Beaujon, Clichy
F-92100, France.
7
INSERM, U773, Centre de Recherché Biomédicale
Bichat-Beaujon, Paris F-75018, France.
GastrointestinalImaging•OriginalResearch
WEB
This is a Web exclusive article.
AJR 2009; 193:W175–W180
0361–803X/09/1933–W175
© American Roentgen Ray Society
P
ancreaticoduodenectomy is safe
in the management of various
malignant and benign diseases
of the pancreatic head and peri-
ampullary region. Although the mortality
rate has decreased to approximately 1–2% at
high-volume centers, the morbidity rate rang-
es from 30% to 50% [1–4]. The two most
frequent complications of pancreaticoduo-
denectomy are delayed gastric emptying and
pancreatic fistula.
Pancreatic fistula after pancreaticoduo-
denectomy is a serious complication result-
ing in prolonged hospital stay, increased
costs, readmission, and a mortality rate of
3–9% [5, 6]. Efforts to reduce the incidence
of pancreatic fistula have included definition
of risk factors [1, 7], improvement of surgical
technique [8, 9], and perioperative adminis-
tration of somatostatin and its analogues [1,
10]. The International Study Group on Pan-
creatic Fistula has defined pancreatic fistula
Keywords: CT, pancreas, pancreaticoduodenectomy,
pancreatic fistula, soft pancreas
DOI:10.2214/AJR.08.1800
Received September 9, 2008; accepted after revision
December 29, 2008.
OBJECTIVE. The purpose of this study was to evaluate the sensitivity and specificity of
routine performance of CT on postoperative day 7 in patients at high risk of pancreatic fistula
after pancreaticoduodenectomy.
MATERIALSANDMETHODS. Two radiologists analyzed images from CT examina-
tions of 50 patients with soft pancreas 7 days after pancreaticoduodenectomy. Pancreatic fistu-
la was defined at CT as a fluid collection close to the pancreaticogastric or pancreaticojejunal
anastomosis. Clinicobiologic criteria for the diagnosis of pancreatic fistula were drain output
of any measurable volume of fluid on or after postoperative day 3 that had an amylase content
more than three times the serum amylase activity. The final diagnosis of pancreatic fistula was
rendered on the basis of clinicobiologic data at hospital discharge or at first readmission.
RESULTS. At hospital discharge or at first readmission, 27 of 50 patients (54%) had a
pancreatic fistula. On postoperative day 7, 30 patients (60%) had a total of 51 fluid collections,
and CT showed a fluid collection close to the pancreaticogastric or pancreaticojejunal anasto-
mosis in 21 of 51 cases. CT had a sensitivity of 63% (17/27 patients) and a specificity of 83%
(19/23 patients) for the diagnosis of pancreatic fistula with four false-positive and 10 false-
negative findings. The diagnosis of pancreatic fistula on the basis of clinicobiologic criteria
on postoperative day 7 was made in 22 of 27 patients (81%), whereas five cases were false-
negative. Four of these patients had CT evidence of pancreatic fistula.
CONCLUSION. In patients at high risk who have undergone pancreaticoduodenectomy,
systematic postoperative CT may be proposed as a complementary tool in the diagnosis of
pancreatic fistula, particularly for detection of clinically occult pancreatic fistula.
Bruno et al.
CT of Pancreatic Fistula
Gastrointestinal Imaging
Original Research