Aims
Postoperative pancreatic fistula (POPF) remains the most significant complication following pancreaticoduodenectomy (PD), and pancreatic parenchymal texture is a key determinant of POPF risk. While intraoperative palpation and histopathological fibrosis assessment are traditional methods to evaluate pancreatic texture, a reliable preoperative tool is lacking. Endoscopic ultrasound (EUS) provides high-resolution evaluation of pancreatic parenchyma. EUS conventional criteria of chronic pancreatitis (EUS CP criteria) has been found to corelate well with pancreatic fibrosis but whether the criteria can predict POPF has not been established. The aim of the study was to evaluate the accuracy of the preoperative EUS CP criteria in predicting POPF and to assess its association with intraoperative pancreatic texture by palpation and histopathological fibrosis.
Methods
A prospective observational study was conducted on patients with benign and malignant periampullary disease undergoing PD. Preoperatively, all patients underwent EUS and CP scoring (0–9). Intraoperative pancreatic texture by palpation and histopathological fibrosis (Klöppel score) were recorded. Comparative analysis was performed between patients with and without POPF.
Results
POPF occurred in 53.8% (21/39), with clinically relevant POPF in 19%. Soft pancreas and non-dilated pancreatic duct were significantly associated with POPF (p=0.003 and p=0.002). EUS CP criteria ≥3 was significantly associated with firm/hard pancreas and lower POPF incidence (16.7%) whereas those with criteria <3 was associated with soft pancreas and higher POPF incidence (60.6%). EUS CP criteria correlated significantly with intraoperative pancreatic texture (p=0.001) and histopathological fibrosis (p=0.005). EUS CP criteria predicted POPF (p=0.047), demonstrating high sensitivity (95%) and NPV (83%) but lower specificity (28%) and PPV (63%), with an overall diagnostic accuracy of 64%.
|
Statistic |
Value |
95% Confidence Interval |
|
Sensitivity |
95.24% |
76.18% to 99.88% |
|
Specificity |
27.78% |
9.69% to 53.48% |
|
Positive Predictive Value |
60.61% |
53.21% to 67.54% |
|
Negative Predictive Value |
83.33% |
39.10% to 97.50% |
|
Accuracy |
64.10% |
47.18% to 78.80% |
Conclusions
Preoperative EUS using the CP criteria reliably predicts pancreatic texture and can serve as a valuable screening tool to identify patients at high risk for POPF prior to PD. Incorporating EUS-based assessment into preoperative planning may enhance risk stratification and guide perioperative management