Impact of pancreatic fat infiltration on postoperative pancreatic fistula occurrence in patients undergoing invagination pancreaticojejunostomy

Published:August 31, 2022DOI:



      No studies to date have determined the impact of pancreatic fat infiltration on postoperative pancreatic fistula (POPF) occurrence in patients undergoing invagination pancreaticojejunostomy (IV-PJ).


      The medical records of patients with a soft pancreas who underwent pancreatoduodenectomy followed by IV-PJ were reviewed . The pancreatic fat ratio on computed tomography (CT) images (I-PFR) was determined using preoperative CT and verified by histologic examination. The relationship between the I-PFR and POPF occurrence was determined. Patients were classified into 2 groups based on I-PFR value (fatty and non-fatty pancreas). Postoperative outcomes were compared between the two groups, and specifically among patients who developed POPF.


      Of 221 patients, POPF occurred in 67 (30.3%). I-PFR was positively correlated with histologic-calculated fat ratio (ρ = 0.517, p < 0.001). This index was shown to be an independent predictor of POPF. Based on an I-PFR cut-off value of 3.2%, 92 patients were classified in the fatty pancreas group. Subgroup analysis of the patients who developed POPF showed that incidence of abscess formation and hemorrhage tended to be higher in patients with fatty pancreas than in those with non-fatty pancreas.


      Pancreatic fat infiltration is highly associated with POPF and possibly causes subsequent serious complications in patients undergoing IV-PJ.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to HPB
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Hirono S.
        • Shimokawa T.
        • Nagakawa Y.
        • Shyr Y.M.
        • Kawai M.
        • Matsumoto I.
        • et al.
        Risk factors for pancreatic fistula grade C after pancreatoduodenectomy: a large prospective, multicenter Japan-Taiwan collaboration study.
        J Hepatobiliary Pancreat Sci. 2020; 27: 622-631
        • Senda Y.
        • Shimizu Y.
        • Natsume S.
        • Ito S.
        • Komori K.
        • Abe T.
        • et al.
        Randomized clinical trial of duct-to-mucosa versus invagination pancreaticojejunostomy after pancreatoduodenectomy.
        Br J Surg. 2018; 105: 48-57
        • Lavu H.
        • McCall N.
        • Keith S.W.
        • Kilbane E.M.
        • Parmar A.D.
        • Hall B.L.
        • et al.
        Leakage of an invagination pancreaticojejunostomy may have an influence on mortality.
        J Pancreat Cancer. 2018; 4: 45-51
        • Feng J.
        • Chen Y.L.
        • Dong J.H.
        • Chen M.Y.
        • Cai S.W.
        • Huang Z.Q.
        Post-pancreaticoduodenectomy hemorrhage: risk factors, managements and outcomes.
        Hepatobiliary Pancreat Dis Int. 2014; 13: 513-522
        • Tanaka K.
        • Yamada S.
        • Sonohara F.
        • Takami H.
        • Hayashi M.
        • Kanda M.
        • et al.
        Pancreatic fat and body composition measurements by computed tomography are associated with pancreatic fistula after pancreatectomy.
        Ann Surg Oncol. 2021; 28: 530-538
        • Tajima Y.
        • Kawabata Y.
        • Hirahara N.
        Preoperative imaging evaluation of pancreatic pathologies for the objective prediction of pancreatic fistula after pancreaticoduodenectomy.
        Surg Today. 2018; 48: 140-150
        • Sugimoto M.
        • Takahashi S.
        • Kojima M.
        • Kobayashi T.
        • Gotohda N.
        • Konishi M.
        In patients with a soft pancreas, a thick parenchyma, a small duct, and fatty infiltration are significant risks for pancreatic fistula after pancreaticoduodenectomy.
        J Gastrointest Surg. 2017; 21: 846-854
        • Tranchart H.
        • Gaujoux S.
        • Rebours V.
        • Vullierme M.P.
        • Dokmak S.
        • Levy P.
        • et al.
        Preoperative CT scan helps to predict the occurrence of severe pancreatic fistula after pancreaticoduodenectomy.
        Ann Surg. 2012; 256: 139-145
        • Belyaev O.
        • Munding J.
        • Herzog T.
        • Suelberg D.
        • Tannapfel A.
        • Schmidt W.E.
        • et al.
        Histomorphological features of the pancreatic remnant as independent risk factors for postoperative pancreatic fistula: a matched-pairs analysis.
        Pancreatology. 2011; 11: 516-524
        • Lee S.E.
        • Jang J.Y.
        • Lim C.S.
        • Kang M.J.
        • Kim S.H.
        • Kim M.A.
        • et al.
        Measurement of pancreatic fat by magnetic resonance imaging: predicting the occurrence of pancreatic fistula after pancreatoduodenectomy.
        Ann Surg. 2010; 251: 932-936
        • Gaujoux S.
        • Cortes A.
        • Couvelard A.
        • Noullet S.
        • Clavel L.
        • Rebours V.
        • et al.
        Fatty pancreas and increased body mass index are risk factors of pancreatic fistula after pancreaticoduodenectomy.
        Surgery. 2010; 148: 15-23
        • Rosso E.
        • Casnedi S.
        • Pessaux P.
        • Oussoultzoglou E.
        • Panaro F.
        • Mahfud M.
        • et al.
        The role of "fatty pancreas" and of BMI in the occurrence of pancreatic fistula after pancreaticoduodenectomy.
        J Gastrointest Surg. 2009; 13: 1845-1851
        • Mathur A.
        • Pitt H.A.
        • Marine M.
        • Saxena R.
        • Schmidt C.M.
        • Howard T.J.
        • et al.
        Fatty pancreas: a factor in postoperative pancreatic fistula.
        Ann Surg. 2007; 246: 1058-1064
        • Bassi C.
        • Marchegiani G.
        • Dervenis C.
        • Sarr M.
        • Abu Hilal M.
        • Adham M.
        • et al.
        The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years after.
        Surgery. 2017; 161: 584-591
        • Dindo D.
        • Demartines N.
        • Clavien P.A.
        Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a surgery.
        Ann Surg. 2004; 240: 205-213
        • Youden W.J.
        Index for rating diagnostic tests.
        Cancer. 1950; 3: 32-35
        • Yang S.H.
        • Dou K.F.
        • Sharma N.
        • Song W.J.
        The methods of reconstruction of pancreatic digestive continuity after pancreaticoduodenectomy: a meta-analysis of randomized controlled trials.
        World J Surg. 2011; 35: 2290-2297
        • Yang Y.M.
        • Tian X.D.
        • Zhuang Y.
        • Wang W.M.
        • Wan Y.L.
        • Huang Y.T.
        Risk factors of pancreatic leakage after pancreaticoduodenectomy.
        World J Gastroenterol. 2005; 11: 2456-2461
        • Wong V.W.
        • Wong G.L.
        • Yeung D.K.
        • Abrigo J.M.
        • Kong A.P.
        • Chan R.S.
        • et al.
        Fatty pancreas, insulin resistance, and β-cell function: a population study using fat-water magnetic resonance imaging.
        Am J Gastroenterol. 2014; 109: 589-597
        • Partelli S.
        • Andreasi V.
        • Schiavo Lena M.
        • Rancoita P.M.V.
        • Mazza M.
        • Mele S.
        • et al.
        The role of acinar content at pancreatic resection margin in the development of postoperative pancreatic fistula and acute pancreatitis after pancreaticoduodenectomy.
        Surgery. 2021; 170: 1215-1222
        • Nahm C.B.
        • Brown K.M.
        • Townend P.J.
        • Colvin E.
        • Howell V.M.
        • Gill A.J.
        • et al.
        Acinar cell density at the pancreatic resection margin is associated with post-pancreatectomy pancreatitis and the development of postoperative pancreatic fistula.
        HPB. 2018; 20: 432-440
        • Olsen T.S.
        Lipomatosis of the pancreas in autopsy material and its relation to age and overweight.
        Acta Pathol Microbiol Scand. 1978; 86a: 367-373