Orthograde Planimetrie der Pankreasschnittfläche anhand der präoperativen Computertomografie zur Risikoeinschätzung einer postoperativen Pankreasfistel nach Pankreaskopfresektion

Zusammenfassung

Einleitung: Die postoperative Pankreasfistel stellt eine zentrale Komplikation nach Pankreaskopfresektionen dar. Die präoperative Detektion von Risikopatienten kann daher sinnvoll sein. Wir untersuchten anhand der präoperativen CT-Diagnostik, ob mithilfe einer Planimetrie (Größe, Durchmesser, Fläche) der erwarteten Resektionsfläche entlang der V. mesenterica superior die Vorhersage einer postoperativen Pankreasfistel möglich ist. Patienten und Methodik: Im Zeitraum von 2009 bis 2013 wurde bei 123 Patienten mit Pankreaskopfresektion eine einheitliche präoperative Diagnostik sowie Operations- und Anastomosentechnik durchgeführt. An einer multiplanaren Rekonstruktion der Pankreasschnittfläche wurden Pankreasdicke, Parenchymdicke, Gangweite, Fläche, Umfang gemessen und die Werte in Quotienten (Gangweite/Pankreasdurchmesser; D/P-Ratio) umgewandelt. Die Daten wurden mit dem postoperativen Auftreten einer Pankreasfistel korreliert. Ergebnisse: Die Planimetrie zeigte einen signifikanten Unterschied der Pankreasschnittfläche in Abhängigkeit vom Auftreten einer postoperativen Pankreasfistel. Ein kräftiges Parenchym und ein zarter Gang waren signifikante Risikofaktoren. Eine Gangweite von weniger als 20 % in Bezug zur Pankreasdicke trat bei 84 bzw. 94 % aller Patienten mit postoperativer Pankreasfistel auf (D/P-Ratio < 0,2; p < 0,01). In der Multivarianzanalyse erwies sich die D/P-Ratio als einziger unabhängiger Risikofaktor. Diskussion: Es besteht ein signifikanter Zusammenhang zwischen der Morphologie der Pankreasschnittfläche und der Häufigkeit einer postoperativen Pankreasfistel. Ab einer D/P-Ratio von < 0,2 nimmt das Risiko deutlich zu.

Abstract

Background: Postoperative pancreatic fistula is a relevant complication after pancreatoduodenectomy. Therefore, preoperative detection of high risk patients may be important. We evaluated preoperative CT-imaging by planimetry at the expected resection plane along the superior mesenteric vein and correlated the results with the incidence of postoperative pancreatic fistula. Patients and Methods: From 2009 to 2013, 123 patients with pancreatoduodenectomy underwent homogenous preoperative imaging and reconstruction of the pancreatojejunostomy. Planimetry was performed at a multiplanar reconstruction of the pancreatic transection plane (diameter, range, duct width, area) as well as the calculation of ratios (duct width/pancreatic diameter; D/P-ratio). The measured values were correlated with the incidence of postoperative pancreatic fistula. Results: Planimetry showed a significant difference of the pancreatic transection plane in relation to the incidence of postoperative pancreatic fistula. A thick parenchyma and a tiny duct are significant risk factors. In 84 % or, respectively, 94 % of the patients with postoperative pancreatic fistula, a duct width of less than 20 % of the pancreatic diameter was observed (D/P ratio < 0.2; p < 0.01). The D/P ratio was the only independent risk factor in multivariate analysis. Discussion: The incidence of postoperative pancreatic fistula correlates significantly with the morphology of the pancreatic transection plane. The risk increases significantly with a D/P ratio of < 0.2.

Schlüsselwörter

Pankreaskopfresektion - postoperative Komplikation - Risikofaktor - bildgebende Verfahren

Key words

pancreatic head resection - postoperative complication - risk factor - imaging procedures

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