Dinter Dietmar J, Aramin Niloufar, Weiss Christel, Singer Christoph, Weisser Gerald, Schoenberg Stefan O, Post Stefan, Niedergethmann Marco
Department of Clinical Radiology and Nuclear Medicine, University Hospital Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany.
J Gastrointest Surg. 2009 Apr;13(4):735-44. doi: 10.1007/s11605-008-0765-7. Epub 2008 Dec 5.
The texture of the pancreatic tissue is a main risk factor for leakage after pancreaticojejunostomy and can be differentiated using dynamic contrast enhanced magnetic resonance imaging (dMRI). In order to identify risk factors and to assess the role of pancreatic dMRI, a cohort of patients was retrospectively reviewed.
One hundred seven consecutive patients were identified in the departmental database and examined by means of a standardized dMRI protocol using a 1.5-T MRI system. Signal intensity (SI) measurements (aorta, body of the pancreas, muscle tissue) were performed in the axial T1-weighted sequences before and after 25 and 60 s after i.v. application of gadolinium-diethylenetriaminepentaacetic acid. For all patients with a standardized contrast medium curve in the aorta (n = 72), a muscle-normalized signal intensity curve (SIC) with SI(ratio) was calculated. SI(ratio)s were classified in two groups: rapid increase (SI(ratio) >or= 1.1, early arterial value > portal-venous value, "soft" pancreas) and delayed increase (SI(ratio) <1.1, "firm" or "hard" pancreas). All patients received pancreatic head resection with a duct-to-mucosa pancreaticojejunostomy. The dMRI data was correlated with prospectively acquired clinical data.
Leakage of the pancreaticojejunostomy occurred more frequently (12/37 vs. two of 35, 32% vs. 6%, p = 0.006) in patients with a rapid increase and an SI(ratio) >or= 1.1 ("soft" pancreas, n = 37) compared to those with delayed perfusion (SI(ratio) <1.1, "hard" pancreas, n = 35). The more severe type B and C anastomotic leakages occurred only in the group of patients with SI(ratio) >or= 1.1. Patients with a rapid increase had significantly better preoperative American Society of Anesthesiologists staging, lower carbohydrate antigen 19-9 values, and smaller tumor sizes. Most of them had not only benign tumors but also longer postoperative hospital stay, in comparison to patients with delayed perfusion (SI(ratio) <1.1). Multivariate analysis revealed SI(ratio) of >or=1.1 to be the only preoperative parameter predicting leakage significantly with an odds ratio of 7.9.
dMRI with SI(ratio) calculation provided reliable information for the prediction of pancreatic texture. Patients with a SI(ratio) >or= 1.1 had a 7.9-fold increased risk of anastomotic leakage and a prolonged hospital stay. SIC with measurements of SI(ratio) in dMRI could therefore define patients at risk for anastomotic leakage.
胰腺组织质地是胰空肠吻合术后发生渗漏的主要危险因素，可通过动态对比增强磁共振成像（dMRI）进行鉴别。为了确定危险因素并评估胰腺dMRI的作用，我们对一组患者进行了回顾性研究。
在科室数据库中识别出107例连续患者，并使用1.5-T MRI系统通过标准化dMRI方案进行检查。在静脉注射钆喷酸葡胺后25秒和60秒前后的轴向T1加权序列中进行信号强度（SI）测量（主动脉、胰腺体部、肌肉组织）。对于所有主动脉中具有标准化对比剂曲线的患者（n = 72），计算具有SI（比值）的肌肉归一化信号强度曲线（SIC）。SI（比值）分为两组：快速升高（SI（比值）≥1.1，动脉早期值＞门静脉期值，“软”胰腺）和延迟升高（SI（比值）＜1.1，“硬”胰腺）。所有患者均接受胰头切除术并进行胰管对黏膜胰空肠吻合术。将dMRI数据与前瞻性获取的临床数据进行关联。
与灌注延迟（SI（比值）＜1.1，“硬”胰腺，n = 35）的患者相比，SI（比值）≥1.1（“软”胰腺，n = 37）且快速升高的患者胰空肠吻合口渗漏更为频繁（12/37对35例中的2例，32%对6%，p = 0.006）。更严重的B型和C型吻合口漏仅发生在SI（比值）≥1.1的患者组中。快速升高的患者术前美国麻醉医师协会分级明显更好，糖类抗原19-9值更低，肿瘤尺寸更小。与灌注延迟（SI（比值）＜1.1）的患者相比，他们大多数不仅患有良性肿瘤，而且术后住院时间更长。多因素分析显示，SI（比值）≥1.1是唯一能显著预测渗漏的术前参数，比值比为7.9。
计算SI（比值）的dMRI为预测胰腺质地提供了可靠信息。SI（比值）≥1.1的患者吻合口漏风险增加7.9倍，住院时间延长。因此，dMRI中测量SI（比值）的SIC可确定有吻合口漏风险的患者。
