Influence of contrast-enhanced computed tomography on course and outcome in patients with acute pancreatitis

INTRODUCTION: Many of the complications in severe acute pancreatitis result from the amplifying effects of microcirculatory disruption. Contrast medium may cause significant additional reductions of capillary flow, which has been shown to aggravate acute pancreatitis in experimental studies. AIM: To investigate the role of serial contrast-enhanced computed tomography (CECT) in patients with acute pancreatitis. METHODOLOGY: A retrospective analysis evaluated 302 patients with moderate to severe acute pancreatitis. Among these patients, 264 underwent CECT within 96 hours of the onset of symptoms and again during the course, but in 38 patients no serial CECT was performed. Outcome measurement was analyzed by comparison of hospital stay and mortality rate between the two patient groups. Influences of contrast medium on severity of disease were detected by monitoring complications during the course of treatment, C-reactive protein, and APACHE II score. RESULTS: The 1-month mortality rate was less in patients with CECT (6.4% versus 15.8%, p <0.05). There were no significant differences considering the incidence of additional complications, and hospital stay was not significantly longer (29 +/- 36 versus 19 +/- 13 days). C-reactive protein and APACHE II score had similar time courses. CONCLUSION: Contrast-enhanced computed tomography remains crucial in identifying patients with acute pancreatitis at high risk to develop necrosis of the pancreas and systemic complications. Contrast medium has been found to aggravate acute pancreatitis in animal models. As compared with the patient group without being exposed to contrast medium, however, this study did not show a deterioration of acute pancreatitis by administration of contrast medium in men.     

Prior history of acute pancreatitis predicts poor survival in patients with resectable pancreatic ductal adenocarcinoma

Background/objectivesMounting evidence has suggested that acute pancreatitis (AP) is a risk factor for pancreatic ductal adenocarcinoma (PDAC), but its role in survival in PDAC patients was rarely investigated. The objective was to investigate the association of a history of AP with survival among PDAC patients who underwent surgical resection.MethodsA retrospective cohort study comprising 632 patients who were diagnosed with resectable PDAC was conducted. Survival was evaluated by history of AP prior to a diagnosis of PDAC using Kaplan-Meier methods and log-rank tests. Multivariate analyses for mortality were estimated using the Cox proportional hazards model. Propensity score matching methods were used to balance the difference of clinical characteristics between patients with and without AP history.ResultsThe log-rank tests showed that patients with a history of AP had a worse overall survival than those without a history of AP (p = 0.006). The multivariable-adjusted hazard ratio (HR) for mortality comparing participants with AP to those without AP was 1.808 (95% CI: 1.241–2.632, p = 0.002). Patients with a recent history of AP (<2 years), rather than patients with a remote history of AP (≥2 years), were found to have significantly worse survival (p = 0.014) than those without a history of AP. After adjusted for PSM, history of AP remained an independent survival predictor of PDAC following surgical resection.ConclusionsOur findings indicate that a history of AP, especially a recent history of AP, is associated with poor survival among patients with resectable pancreatic ductal adenocarcinoma.     

从胰腺的受累部位探讨急性胰腺炎的发病机制

目的分析胰腺炎时胰腺的常见累及部位及病因，初步探讨急性胰腺炎的发病机制。方法对2000年2月～2010年10月在我院住院的408例急性胰腺炎患者的累及部位及病因作回顾分析。结果74．0％患者为高脂血症导致的胰腺炎；100％胰腺炎患者胰腺尾部受累，83．8％患者为胰腺尾部或体尾部受累。高脂血症性胰腺炎以体尾部或头体尾部同时受累为主，胆源性胰腺炎主要以胰腺尾部或体尾部受累为主，两者比较差异显著（X^2=96．1，P〈0．01）。轻症胰腺炎主要为胰腺尾部和／或体尾部受累；重症胰腺炎主要为体尾部或整个胰腺受累。两者在受累部位方面比较具有显著差异（X^2=187．5，P〈0．01）。胆源性胰腺炎主要是轻症胰腺炎，高脂血症性胰腺炎中重症胰腺炎的发生率明显高于胆源性胰腺炎。两者相比差异显著（X^2=10．9，P〈0．05）。结论胰腺炎的受累部位提示胰腺炎的发生除胰酶激活引起自身消化之外，胰腺微循环障碍造成胰腺实质缺血缺氧亦是重要的发病机制。对于胰腺炎的治疗除了抑制胰液分泌，抑制胰酶活性之外，改善胰腺微循环亦是非常重要的措施。     

Patient-derived xenograft model engraftment predicts poor prognosis after surgery in patients with pancreatic cancer

ObjectivesTo establish and evaluate a first generation patient-derived xenograft (PDX) model in nude mice using tumors resected from pancreatic cancer (PC) patients for the identification of key factors that influence xenograft success and prediction of patient prognosis.MethodsPrimary tumor samples harvested from PC patients who underwent curative resection between May 2016 and April 2018 at our hospital were xenografted into nude mice. Tumor size was evaluated for 2 months. Patients’ baseline characteristics and follow-up data were analyzed.ResultsTumor xenograft models were generated from 67 patients; 30 (44.8%) were successful and 37 (55.2%) failed. Xenograft models could recapitulate the pathology and genetic information of the primary tumors. Univariate analysis identified tumor engraftment, post-operation CA19-9, tumor size, lymph node status, and lymphovascular invasion as significant predictors (P=0.000, 0.023, 0.004, 0.035 and 0.005, respectively) of disease-free survival (DFS). Multivariate Cox regression analysis confirmed tumor engraftment, tumor size and lymphovascular invasion function as independent risk factors for DFS (P=0.000, 0.039 and 0.025, respectively). The hazard ratio of tumor engraftment for DFS was 0.239 (95% confidence interval, 0.109 to 0.524). Kaplan–Meier analysis of DFS indicated an unfavorable outcome in the engraftment group compared to that in the failed engraftment group (6.2 vs. 12.2 months, log rank P=0.000).ConclusionThe pathology and genetic information of primary PC tumors are recapitulated in the PDX tumor model in nude mice. Furthermore, engraftment success is an effective predictor of disease recurrence in patients after surgery.     

Contrast-enhancement ratio on multiphase enhanced computed tomography predicts recurrence of pancreatic neuroendocrine tumor after curative resection

Background/ObjectiveNo previous study has quantitatively investigated the degree of enhancement of pancreatic neuroendocrine tumors (pNETs) using a routine preoperative modality. The aim of this study was to evaluate the contrast-enhancement ratio (CER) of pNETs using multiphase enhanced CT and to assess the impact of the CER on disease recurrence after surgery.MethodsA retrospective study was performed using data from 47 consecutive patients with pNETs who had undergone curative surgery. The CER of the tumor was calculated by dividing the CT attenuation value obtained during the maximum-enhanced phase by that obtained during the pre-enhanced phase. A region of interest was placed in the largest tumor dimension plane so as to cover as much surface of the tumor as possible while avoiding adjacent normal structures, calcification, and necrotic areas of the tumor.ResultsDuring a median follow-up period of 51 months (range, 1–132 months), a total of 4 patients (8.5%) developed disease recurrence. The median CER value was significantly lower for the patients with recurrence than for the patients without recurrence (2.9 vs. 4.3, P = 0.013). Univariate analyses showed that a CER ≤3.2 was significantly associated with disease recurrence (P < 0.001). All the patients with disease recurrence had tumors that were both large (>20 mm) and weakly enhanced (CER ≤ 3.2), whereas no recurrences were observed even in patients with tumors >20 mm when the CER was greater than 3.2.ConclusionsCER might be a useful predictor of disease recurrence in patients with pNETs.     

Diagnosing acute pancreatitis and assessing its severity by enhanced computed tomography: Correlations with Ranson’s assessment method

Using the criteria of the Japanese Ministry of Health and Welfare for evaluation of the severity of acute pancreatitis based on computed tomography (CT), we assessed the CT grade of 104 patients with acute pancreatitis. The CT assessments were compared with the status of acute pancreatitis in these patients, assessed using Ranson’s system of objective prognostic signs by which acute pancreatitis is classified as “mild”, “moderate”, or “severe.” A CT grade of I corresponded to Ranson’s mild category; CT grades II and III corresponded to moderate, and CT grades IV and V corresponded to servere. Some patients with a CT grade of IV or V died, whereas none of the patients with CT grades of I, II, or III succumbed to the condition. This study confirmed that enhanced CT provides an accurate CT grading of acute pancreatitis. We emphasize the necessity of using enhanced CT for determining the severity of acute pancreatitis, not only on admission but also during hospitalization if the patient’s condition should become exacerbated.     

Contrast-enhanced computed tomography of the gallbladder in acute pancreatitis

The gallbladder findings encountered in 59 patients examined because of a first attack of acute, alcohol-induced pancreatitis, are reported. Abdominal contrast-enhanced computed tomography was technically acceptable in 54 patients. In 85% of the patients the gallbladder finding was pathological. The density increase in the gallbladder contents was more than twice normal. Possible reasons for this phenomenon are discussed. Intense contrast enhancement of the gallbladder wall was found in 87% of the cases. Increased wall thickness was observed in 64% of the patients.     

A modified alternative fistula risk score (a-FRS) obtained from the computed tomography enhancement pattern of the pancreatic parenchyma predicts pancreatic fistula after pancreatoduodenectomy

BackgroundAlternative fistula risk score (a-FRS) is useful to predict clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreatoduodenectomy (PD).MethodsClinical data from 239 patients undergoing PD were collected. The CT value of the pancreatic parenchyma was measured in the nonenhanced (N), arterial (A), portal venous (P), and late (L) phases. The A/N, A/P, P/L and A/L ratios were calculated and their correlation with CR-POPF were analyzed. By replacing pancreatic texture with the best CT attenuation ratio, a modified a-FRS was developed.ResultsForty-seven patients developed CR-POPF. The A/P ratio (P < 0.001), P/L ratio (P = 0.002) and A/L ratio (P < 0.001) were significantly higher in the CR-POPF group. The A/L ratio performed best in predicting CR-POPF (AUC: 0.803) and the cut-off value is 1.36. A/L ratio >1.36 (P < 0.001), body mass index (P = 0.005) and duct diameter (P = 0.037) were independently associated with CR-POPF. By replacing soft texture with an A/L ratio >1.36, a modified a-FRS was developed and performed better than the a-FRS (AUC: 0.823 vs 0.748, P = 0.006) in predicting CR-POPF.ConclusionsThe modified a-FRS is an objective and preoperative model for predicting the occurrence of CR-POPF after PD.     

四维CT血管造影评估的急性缺血性脑卒中患者脑侧支循环与预后的相关性

目的 应用动态四维CT血管造影(4D-CTA)评价急性缺血性脑卒中(AIS)患者脑侧支循环状态并分析患者脑侧支循环状态与其预后的相关性。方法 收集2020年1月至9月江苏省滨海县人民医院最终纳入研究的47例AIS患者的基线资料及影像学变量资料。所有患者均于发病4.5 h内接受4D-CTA检查,应用多时相CTA(mCTA)脑侧支循环评分与区域软脑膜侧支循环(rLMC)评分对AIS患者脑侧支循环状态进行评估,并采用90 d改良Rankin量表(mRS)评估其神经功能预后。根据mRS评分结果将患者分为侧支循环不良组(19例)与侧支循环良好组(28例)。采用SPSS 25.0软件分析数据,根据数据类型,分别采用χ²检验、t检验或秩和检验进行组间比较。采用Spearman相关分析各指标间的相关性。应用logistic回归分析影响AIS患者神经功能预后不良的指标,并进一步绘制受试者工作特征(ROC)曲线探讨不同指标的预测价值。结果 与侧支循环良好组相比,侧支循环不良组美国国立卫生研究院卒中量表(NIHSS)评分更高,半影体积(Tmax>6 s)及梗死核心体积(rCBF&...     

Effects of infective necrosis on poor prognosis in acute pancreatitis

正Objective To evaluate the effects of infective necrosis(IN)on prognosis in moderately severe or severe acute pancreatitis(AP).Methods According to the revi-sion of Atlanta classification,from January 2001 to January 2015,admitted patients with moderately severe or severe AP were retrospectively analyzed.According to the     

Prognostic significance of extracellular volume fraction with equilibrium contrast-enhanced computed tomography for pancreatic neuroendocrine neoplasms

Background/Objectives: Identifying reliable pretreatment imaging biomarkers for pancreatic neuroendocrine neoplasm (PanNEN) is a key imperative. Extracellular volume (ECV) fraction quantified with equilibrium contrast-enhanced CT can be easily integrated into routine examinations. This study aimed to determine whether ECV fraction with equilibrium contrast-enhanced computed tomography (CECT) could predict long-term outcomes in patients with PanNEN.MethodsThis study was a retrospective observational study of 80 patients pathologically diagnosed with PanNEN at a single institution. ECV fraction of the primary lesion was calculated using region-of-interest measurement within PanNEN and the aorta on unenhanced and equilibrium CECT. The impact of clinical factors and tumor ECV fraction on progression-free survival (PFS) and overall survival (OS) was assessed with univariate and multivariate analyses using Cox proportional hazards models. The correlation between WHO classification and tumor ECV fraction was evaluated using Kendall rank correlation coefficients.ResultsPFS and OS rates were estimated as 93.4% and 94.6%, 78.7% and 86.2%, 78.7% and 77.0%, and 78.7% and 66.6% at 1, 3, 5, and 10 years, respectively. Multivariate analysis revealed that Union for International Cancer Control (UICC) stage (hazard ratio [HR] = 3.95, P = 0.003), WHO classification (HR = 12.27, P = 0.003), and tumor ECV fraction (HR = 11.93, P = 0.039) were independent predictors of PFS. Patient age (HR = 1.11, P < 0.001), UICC stage (HR = 3.14, P = 0.001), and tumor ECV fraction (HR = 5.27, P = 0.024) were independent significant variables for predicting OS. Tumor ECV fraction had a weak inverse relationship with WHO classification (P = 0.045, τ = ?0.178).ConclusionsECV fraction determined by equilibrium CECT and UICC stage may predict survival in patients with PanNEN.     

Enhancement parameters of contrast-enhanced computed tomography for pancreatic ductal adenocarcinoma: Correlation with pathologic grading

BACKGROUND Pancreatic ductal adenocarcinoma(PDA) is a malignancy with a high mortality rate and short survival time. The conventional computed tomography(CT) has been worldwide used as a modality for diagnosis of PDA, as CT enhancement pattern has been thought to be related to tumor angiogenesis and pathologic grade of PDA.AIM To evaluate the relationship between the pathologic grade of pancreatic ductal adenocarcinoma and the enhancement parameters of contrast-enhanced CT.METHODS In this retrospective study, 42 patients(Age, mean ± SD: 62.43 ± 11.42 years) with PDA who underwent surgery after preoperative CT were selected. Two radiologists evaluated the CT images and calculated the value of attenuation at the aorta in the arterial phase and the pancreatic phase(VA_(arterial) and VApancreatic) and of the tumor(VT_(arterial) and VT_(pancreatic)) by finding out four regions of interest. Ratio between the tumor and the aorta enhancement on the arterial phase and the pancreatic phase(TAR_(arterial) and TAR_(pancreatic)) was figured out through dividing VT_(arterial) by VA_(arterial) and VT_(pancreatic) by VA_(pancreatic). Tumor-to-aortic enhancement fraction(TAF) was expressed as the ratio of the difference between attenuation of the tumor on arterial and parenchymal images to that between attenuation of the aorta on arterial and pancreatic images. The Kruskal-Wallis analysis of variance and Mann-Whitney U test for statistical analysis were used.RESULTS Forty-two PDAs(23 men and 19 women) were divided into three groups: Welldifferentiated(n = 13), moderately differentiated(n = 21), and poorly differentiated(n = 8). TAF differed significantly between the three groups(P = 0.034) but TAR_(arterial)(P = 0.164) and TAR_(pancreatic)(P = 0.339) did not. The median value of TAF for poorly differentiated PDAs(0.1011; 95%CI: 0.01100-0.1796) was significantly higher than that for well-differentiated PDAs(0.1941; 95%CI: 0.1463-0.3194).CONCLUSION Calculation of TAF might be useful in predicting the pathologic grade of PDA.     

Staging of severity and prognosis of acute pancreatitis by computed tomography and magnetic resonance imaging—A comparative study

BACKGROUND: Determination of severity of acute pancreatitis is important to determine prognosis. AIMS: (1) the staging of acute pancreatitis by computed tomography and magnetic resonance imaging, (2) the correlation of computed tomography and magnetic resonance severity indices and 3) the correlation of magnetic resonance severity index with C-reactive protein, Ranson score, duration of hospitalization and clinical outcome. PATIENTS: Thirty-five patients (median age: 64 (27-89)) were studied. Twenty-two patients had biliary acute pancreatitis. METHODS: The following examinations were conducted: (1) computed tomography 48 h, 7 and 30 days after admission, (2) magnetic resonance imaging 7 and 30 days after admission, (3) C-reactive protein and 4) Ranson score. Clinical outcome was determined on a scale 0-3 (0: remission, 1: local complications, 2: systemic complications, 3: death). RESULTS: Six of 35 patients (17%) had necrotizing acute pancreatitis. Fifteen of 35 patients (43%) had severe acute pancreatitis according to Ranson criteria. A significant correlation was noted between magnetic resonance severity index and C-reactive protein (r=0.419, p<0.005), Ranson score (r=0.431, p<0.05), duration of hospitalization (r=0.497, p<0.01) and clinical outcome (r=0.420, p<0.05). Comparison of the imaging methods showed a significant correlation between magnetic resonance severity index and computed tomography severity index (r=0.887, p<0.01). CONCLUSION: Magnetic resonance imaging is of comparable diagnostic and prognostic value with computed tomography in the staging of acute pancreatitis.     

Management of complicated acute pancreatitis: Impact of computed tomography

The usefulness of computed tomography (CT) in guiding the management of 43 patients who had a complicated clinical course of acute pancreatitis was retrospectively studied. The CT scans were performed when patients had persistent fever, leucocytosis, hyperamylasaemia, palpable abdominal masses or when there was organ failure. The CT scans showed normal findings in six patients, features of pancreatic abscess in three patients, pseudocysts in three patients and inflammatory masses (a mixture of sterile inflammation and necrosis) in 31 patients. Patients with pancreatic abscesses underwent emergency laparotomy, drainage and debridement; patients with pseudocysts had delayed drainage unless complication occurred; patients with normal CT scan or findings of inflammatory masses were managed conservatively. For patients undergoing conservative management, repeated CT scanning and percutaneous aspiration of the inflammatory mass was performed when pancreatic sepsis was strongly suspected. By this approach, basing on careful clinical and CT scan surveillance, five patients with pancreatic sepsis (pancreatic abscess and localized abscess collection in pseudocyst) underwent emergency surgery and four survived, while 25 patients with inflammatory masses were successfully managed conservatively and some who may have been operated on clinical grounds were spared unnecessary early debridement surgery.