Risk factors for postoperative pancreatic fistula after pancreaticoduodenectomy: the significance of the ratio of the main pancreatic duct to the pancreas body as a predictor of leakage

Postoperative pancreatic fistula (POPF) is a severe and frequent complication after pancreaticoduodenectomy (PD). The aim of this study was to identify an independent predictor of POPF and to assess the efficacy of preoperative multidetector row computed tomography (MDCT) images as an indicator for POPF. A total of 122 patients who underwent PD with an end-to-side, duct-to-mucosa pancreaticojejunostomy between January 2005 and May 2009 were retrospectively reviewed. The diameter of the main pancreatic duct (MPD), the diameter of the short axis of the pancreas body, and the ratio of the MPD to the pancreas body (MPD index) were digitally measured based on the curved reformatted images of preoperative MDCT. Postoperative pancreatic fistula occurred in 33 patients (27%). The operative mortality rate was 3.3% (4 patients). All four patients had grade C POPF. Three died because of hemorrhage from a pseudoaneurysm of the gastroduodenal artery stump, and one died because of sepsis due to major leakage from the pancreaticojejunostomy. In a multivariate analysis, the intraoperative blood loss (/100 ml) [odds ratio (OR), 1.1; 95% confidence interval (CI), 1.05-1.17] and MPD index (< 0.2) (OR 50; 95% CI 6-41) proved to be independent predictors of POPF. In patients with an MPD index of < 0.2, the incidence of POPF was 45%, and the mortality rate was 7.5%. The MPD index obtained from preoperative MDCT can be a reliable predictor of POPF after PD.