Research Article|Articles in Press

Acute pancreatitis after pancreatoduodenectomy: A prospective study of diffusion-weighted magnetic resonance imaging, serum biomarkers, and clinical features

Published:March 18, 2023DOI:



      Postpancreatectomy acute pancreatitis is challenging to diagnose and poorly characterized in its early phases. However, it represents the ideal target for novel therapeutic opportunities possibly gleaned from medical acute pancreatitis. This study aims to systematically investigate early radiologic, biochemical, and clinical features of postpancreatectomy acute pancreatitis.


      This was a prospective observational study of patients undergoing pancreatoduodenectomy from September 2019 to January 2021. Diffusion-weighted magnetic resonance imaging was performed on postoperative day 3. Serum pancreatic amylase and lipase were assessed daily until postoperative day 5. Postoperative serum hyperamylasemia and postpancreatectomy acute pancreatitis were defined based on the International Study Group for Pancreatic Surgery definition.


      A total of 65 patients were enrolled according to the sample size calculation. Patients with postoperative serum hyperamylasemia and postpancreatectomy acute pancreatitis had significantly lower apparent diffusion coefficient values at diffusion-weighted magnetic resonance imaging but no macroscopic features consistent with acute pancreatitis. Subsequently, 21 patients (32.3%) underwent computed tomography imaging for clinical worsening, and 6 had radiologic features of acute pancreatitis. All these latter patients had postoperative serum hyperamylasemia and worse outcomes, characterized by local (postoperative pancreatic fistula: 83%) and systemic morbidity (sepsis: 66.7%). The postoperative serum hyperamylasemia incidence was 21.5% (n = 14), and postpancreatectomy acute pancreatitis occurred in 6 patients (9.2%), with 4 grade B (6.1%) and 2 grade C (3%).


      Postpancreatectomy acute pancreatitis is characterized by early serum hyperamylasemia and hyperlipasemia. Although pancreatic changes may appear at postoperative day 3 diffusion-weighted magnetic resonance imaging, its standard use has no impact on postoperative management. Macroscopic radiologic features appear later and correlate with worse clinical scenarios. This paper paves the ground for including postpancreatectomy acute pancreatitis in the spectrum of acute pancreatitis, promoting the transfer of treatment strategies for acute pancreatitis into managing postpancreatectomy acute pancreatitis.
      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 Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Banks P.A.
        • Bollen T.L.
        • Dervenis C.
        • et al.
        Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus.
        Gut. 2013; 62: 102-111
        • Marchegiani G.
        • Barreto S.G.
        • Bannone E.
        • et al.
        Postpancreatectomy acute pancreatitis (PPAP): definition and grading from the International Study Group for Pancreatic Surgery (ISGPS).
        Ann Surg. 2022; 275: 663-672
        • Bannone E.
        • Andrianello S.
        • Marchegiani G.
        • et al.
        Postoperative hyperamylasemia (POH) and acute pancreatitis after pancreatoduodenectomy (POAP): state of the art and systematic review.
        Surgery. 2021; 169: 377-387
        • Bannone E.
        • Marchegiani G.
        • Balduzzi A.
        • et al.
        Early and sustained elevation in serum pancreatic amylase activity: a novel predictor of morbidity after pancreatic surgery.
        Ann Surg. 2023; 277: e126-e135
        • Loos M.
        • Strobel O.
        • Dietrich M.
        • et al.
        Hyperamylasemia and acute pancreatitis after pancreatoduodenectomy: two different entities.
        Surgery. 2021; 169: 369-376
        • Arvanitakis M.
        • Delhaye M.
        • De Maertelaere V.
        • et al.
        Computed tomography and magnetic resonance imaging in the assessment of acute pancreatitis.
        Gastroenterology. 2004; 126: 715-723
        • Rocha A.P.C.
        • Schawkat K.
        • Mortele K.J.
        Imaging guidelines for acute pancreatitis: when and when not to image.
        Abdom Radiol. 2020; 45: 1338-1349
        • Tonolini M.
        • Di Pietro S.
        Diffusion-weighted MRI: new paradigm for the diagnosis of interstitial oedematous pancreatitis.
        Gland Surg. 2019; 8: 197-206
        • Cuthbertson C.M.
        • Christophi C.
        Disturbances of the microcirculation in acute pancreatitis.
        Br J Surg. 2006; 93: 518-530
        • Le Bihan D.
        • Breton E.
        • Lallemand D.
        • et al.
        MR imaging of intravoxel incoherent motions: application to diffusion and perfusion in neurologic disorders.
        Radiology. 1986; 161: 401-407
        • Thomas S.
        • Kayhan A.
        • Lakadamyali H.
        • et al.
        Diffusion MRI of acute pancreatitis and comparison with normal individuals using ADC values.
        Emerg Radiol. 2012; 19: 5-9
        • von Elm E.
        • Altman D.G.
        • Egger M.
        • et al.
        The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.
        Ann Intern Med. 2007; 147: 573-577
        • Pallmann P.
        • Bedding A.W.
        • Choodari-Oskooei B.
        • et al.
        Adaptive designs in clinical trials: why use them, and how to run and report them.
        BMC Med. 2018; 16: 29
        • Kieser M.
        • Friede T.
        Simple procedures for blinded sample size adjustment that do not affect the type I error rate.
        Stat Med. 2003; 22: 3571-3581
        • Bannone E.
        • Andrianello S.
        • Marchegiani G.
        • et al.
        Postoperative acute pancreatitis following pancreaticoduodenectomy: a determinant of fistula potentially driven by the intraoperative fluid management.
        Ann Surg. 2018; 268: 815-822
        • Bassi C.
        • Marchegiani G.
        • Dervenis C.
        • 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
        • Wente M.N.
        • Veit J.A.
        • Bassi C.
        • et al.
        Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition.
        Surgery. 2007; 142: 20-25
        • Wente M.N.
        • Bassi C.
        • Dervenis C.
        • et al.
        Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS).
        Surgery. 2007; 142: 761-768
        • Borchardt R.A.
        • Tzizik D.
        Update on surgical site infections: the new CDC guidelines.
        JAAPA. 2018; 31: 52-54
        • Levy M.M.
        • Fink M.P.
        • Marshall J.C.
        • et al.
        2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference.
        Crit Care Med. 2003; 31: 1250-1256
        • Khwaja A.
        KDIGO clinical practice guidelines for acute kidney injury.
        NEC. 2012; 120: c179-c184
        • 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 survey.
        Ann Surg. 2004; 240: 205-213
        • Bakdash J.Z.
        • Marusich L.R.
        Repeated measures correlation.
        Front Psychol. 2017; 8: 456
        • Bannone E.
        • Marchegiani G.
        • Perri G.
        • et al.
        Postoperative serum hyperamylasemia (POH) predicts additional morbidity after pancreatoduodenectomy: it is not all about pancreatic fistula.
        Surgery. 2022; 172: 715-722
        • Bannone E.
        • Marchegiani G.
        • Vollmer C.
        • et al.
        Postoperative serum hyperamylasemia (POH) adds sequential value to the Fistula Risk Score (FRS) in predicting pancreatic fistula after pancreatoduodenectomy [e-pub ahead of print]. Ann Surg.
        • Lee P.J.
        • Papachristou G.I.
        New insights into acute pancreatitis.
        Nat Rev Gastroenterol Hepatol. 2019; 16: 479-496
        • Romac J.M.-J.
        • Shahid R.A.
        • Swain S.M.
        • et al.
        Piezo1 is a mechanically activated ion channel and mediates pressure induced pancreatitis.
        Nat Commun. 2018; 9: 1715
        • Manes G.
        • Rabitti P.G.
        • Laccetti M.
        • et al.
        Early prediction of aetiology and severity of acute pancreatitis by serum amylase and lipase assays.
        Minerva Gastroenterol Dietol. 1995; 41: 211-215
        • Khanna A.K.
        • Meher S.
        • Prakash S.
        • et al.
        Comparison of Ranson, Glasgow, MOSS, SIRS, BISAP, APACHE-II, CTSI scores, IL-6, CRP, and procalcitonin in predicting severity, organ failure, pancreatic necrosis, and mortality in acute pancreatitis.
        HPB Surg. 2013; 2013: 367581
        • Welsch T.
        • Frommhold K.
        • Hinz U.
        • et al.
        Persisting elevation of C-reactive protein after pancreatic resections can indicate developing inflammatory complications.
        Surgery. 2008; 143: 20-28
        • Wu S.
        • Wu H.
        • Xu G.
        • et al.
        Risk factors and clinical impacts of post-pancreatectomy acute pancreatitis after pancreaticoduodenectomy: a single-center retrospective analysis of 298 patients based on the ISGPS definition and grading system.
        Front Surg. 2022; 9: 916486
        • Chen H.
        • Wang C.
        • Shen Z.
        • et al.
        Post-pancreatectomy acute pancreatitis after pancreaticoduodenectomy: a distinct clinical entity[e-pub ahead of print]. Ann Surg.
        • Ikenaga N.
        • Nakata K.
        • Fujita N.
        • et al.
        Clinical significance of postpancreatectomy acute pancreatitis defined by the International Study Group for Pancreatic Surgery.
        Ann Gastroenterol Surg. 2022; 6: 842-850
        • Crockett S.D.
        • Wani S.
        • Gardner T.B.
        • et al.
        American Gastroenterological Association Institute guideline on initial management of acute pancreatitis.
        Gastroenterology. 2018; 154: 1096-1101
        • Lassen K.
        • Coolsen M.M.E.
        • Slim K.
        • et al.
        Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS) Society recommendations.
        Clin Nutr. 2012; 31: 817-830
        • Choi J.-H.
        • Kim H.J.
        • Lee B.U.
        • et al.
        Vigorous periprocedural hydration with lactated Ringer’s solution reduces the risk of pancreatitis after retrograde cholangiopancreatography in hospitalized patients.
        Clin Gastroenterol Hepatol. 2017; 15: 86-92.e1
        • Bulyez S.
        • Pereira B.
        • Caumon E.
        • et al.
        Epidural analgesia in critically ill patients with acute pancreatitis: the multicentre randomized controlled EPIPAN study protocol.
        BMJ Open. 2017; 7e015280
        • Salvia R.
        • Marchegiani G.
        • Andrianello S.
        • et al.
        Redefining the role of drain amylase value for a risk-based drain management after pancreaticoduodenectomy: early drain removal still is beneficial.
        J Gastrointest Surg. 2021; 25: 1461-1470
        • Khurana A.
        • Nelson L.W.
        • Myers C.B.
        • et al.
        Reporting of acute pancreatitis by radiologists-time for a systematic change with structured reporting template.
        Abdom Radiol (NY). 2020; 45: 1277-1289
        • Bradley E.L.
        A clinically based classification system for acute pancreatitis: summary of the International Symposium on Acute Pancreatitis, Atlanta, GA, September 11 through 13, 1992.
        Arch Surg. 1993; 128: 586-590