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24
Figure Legends
Figure 1 Measurement of CT findings and pancreatic acinar cell density
(a) The CT attenuation value of the liver was defined as the mean of the attenuation value of four ROIs
in different sectors in the liver. (b) The CT attenuation value of the remnant pancreas was defined as
the mean of two ROIs in the remnant pancreas on preoperative unenhanced CT. (c) The vessels were
excluded by reviewing the preoperative enhanced CT. (d) The cut line of the pancreas was determined
by the location of the pancreatojejunostomy in the postoperative CT images. (e) Subsequently, the
remnant pancreatic parenchyma was manually outlined on each CT slice using a free-hand region of
interest in the preoperative CT images and the volume of the remnant pancreas was calculated using all
10
outlined areas and the slice thickness. (f) The pancreatic acinar cell density was measured by Image J
11
(f, except red area) at 100x magnification of hematoxylin and eosin stained tissue (g).
12
Abbreviations: CT, computed tomography; ROI, region of interest
13
14
Figure 2 Relationship between the preoperative CT attenuation value of the remnant pancreas and the
15
pancreatic acinar cell density
16
(a) The scatter diagram shows the relationship between the preoperative CT attenuation value of the
17
remnant pancreas and the pancreatic acinar cell density. These two factors are positively correlated,
18
with a Pearson’s correlation coefficient of 0.537. (b) The ROC curve of the CT attenuation value of
19
the remnant pancreas for the analysis of the pancreatic acinar cell density ≥ 50% has an area under the
25
curve of 0.829. A cutoff value of 37.0 HU predicts pancreatic acinar cell density ≥ 50% with a
sensitivity and specificity of 71.4% and 85.2%, respectively. (c) The scatter diagram shows the
relationship between the preoperative CT attenuation value of the remnant pancreas and the fibrotic
score. These two factors are negatively correlated, with a Pearson’s correlation coefficient of -0.532.
Abbreviations: CT, computed tomography; HU, Hounsfield units; ROC, receiver operating
characteristic
Figure 3 The estimated functional remnant pancreatic volume as a predictor of nonalcoholic fatty liver
disease.
10
The ROC curve of the eFRPV for the prediction of NAFLD has an area under the curve of 0.721. A
11
cut-off value of 47.0 mL·HU predicts NAFLD with a sensitivity and specificity of 81.0% and 65.6%,
12
respectively. Abbreviations: eFRPV, estimated functional remnant pancreatic volume; NAFLD,
13
nonalcoholic fatty liver disease; ROC, receiver operating characteristic; HU, Hounsfield units
14
26
Tables
Table 1. Clinical features of the NAFLD and non-NAFLD groups
NAFLD group
non-NAFLD group
P-value
(n=21)
(n=91)
Background
63 (69.2%)
Sex, male / female
10 / 11
0.077
/ 28 (30.8%)
Age, years
68 (62-71)
69 (62-75)
0.438
22.0 (19.4-23.3)
21.48 (19.6-23.8)
0.864
Prevalence of hypertension
31 (34.1%)
0.444
Prevalence of diabetes mellitus
21 (23.1%)
0.099
Alcohol intake >20g/day
28 (30.8%)
1.000
Use of steroid agent
2 (2.2%)
1.000
Preoperative biliary drainage
10
41 (45.1%)
1.000
Neoadjuvant chemotherapy
3 (3.3%)
0.006
Preoperative NAFLD
1 (1.1%)
0.341
Prevalence of liver dysfunction
3 (3.3%)
0.038
Body mass index, kg/m2
Pathological diagnosis
< 0.001
27
Pancreatic cancer
19
30 (33.0%)
Intraductal papillary mucinous neoplasm
14 (15.4%)
Chronic pancreatitis
2 (2.2%)
Pancreatic neuroendocrine neoplasm
4 (4.4%)
Bile duct cancer
21 (23.1%)
Cancer of the papilla of vater
12 (13.2%)
Others
8 (8.7%)
13.0 (11.8-13.6)
12.6 (11.9-13.8)
0.911
5000 (4400-7500)
5300 (4350-6400)
0.765
22.2 (18.9-28.7)
21.5 (17.9-26.1)
0.293
Prothrombin activity, %
99 (88-103)
94 (87-103)
0.740
Aspartate aminotransferase, U/L
29 (20-41)
22 (19-33)
0.174
Alanine aminotransferase, U/L
24 (18-65)
22 (16-48)
0.365
343 (241-433)
267 (200-440)
0.256
Total bilirubin, g/dL
0.93 (0.59-1.56)
0.84 (0.58-1.34)
0.472
Creatinine, mg/dL
0.59 (0.52-0.81)
0.74 (0.63-0.90)
0.015
Preoperative laboratory data
Hemoglobin, g/dL
White blood cell count, /μL
Platelet count, /μL
Alkaline phosphatase, U/L
28
Amylase, U/L
68 (45-116)
79 (63-128)
0.093
Lipase, U/L
58 (15-109)
46 (31-99)
0.486
Creatine kinase, U/L
50 (30-69)
59 (38-74)
0.132
0.10 (0.05-0.32)
0.12 (0.05-0.37)
0.765
Total protein, g/dL
6.4 (6.2-6.8)
6.6 (6.4-7.1)
0.091
Albumin, g/dL
3.5 (3.4-4.0)
3.7 (3.4-4.0)
0.598
Cholinesterase, U/L
275 (244-292)
263 (221-295)
0.351
Total cholesterol, mg/dL
195 (164-235)
187 (148-216)
0.310
Triglyceride, mg/dL
118 (87-140)
120 (92-148)
0.967
Hemoglobin A1c, %
6.0 (5.7-6.6)
5.9 (5.6-6.7)
0.916
Total lymphocyte count, /μL
1442 (1220-1895)
1531 (1210-2056)
0.685
Prognostic nutritional index
43.73 (40.26-49.49)
45.06 (42.53-48.23)
0.679
2 (1-3)
2 (1-3)
0.774
689 (500.0-1491)
791 (469.5-1435)
0.929
C-reactive protein, mg/dL
Preoperative nutritional status
CONUT score
Intraoperative findings
Blood loss, mL
29
Operation time, minutes
537 (489.0-566)
463 (403.5-586)
0.106
Presence of transfusion
18 (19.8%)
0.765
Diameter of MPD, mm
5 (2-6)
3 (3-5)
0.060
53 (58.2%)
Pancreatic stiffness, soft / hard
4 / 17
0.001
/ 38 (41.8%)
Postoperative findings
Complication ≥ grade3
45 (49.5%)
0.635
Postoperative pancreatic fistula grade B/C
30 (33.0%)
0.114
16
45 (49.5%)
0.031
17
34 (37.4%)
<0.001
9/17
22/34
0.545
10 (8.9%)
1.000
Postoperative pancreatic enzyme
supplementation
Adjuvant chemotherapy
Adjuvant chemotherapy completely
Recurrence within 6 months
Postoperative nutritional status (6 months after surgery)
Total protein, g/dL
6.3 (5.6-6.7)
6.8 (6.3-7.1)
0.006
Albumin, g/dL
3.5 (3.2-3.7)
3.8 (3.2-4.0)
0.049
30
Cholinesterase, U/L
183 (138-220)
213 (164-269)
0.077
Total cholesterol, mg/dL
123 (110-129)
148 (126-178)
0.001
Triglyceride, mg/dL
79 (71-102)
77 (67-115)
1.000
Hemoglobin A1c, %
5.7 (5.3-6.2)
5.8 (5.4-6.4)
0.368
Total lymphocyte count, /μL
1084 (930-1288)
1385 (933-1774)
0.057
Prognostic nutritional index
40.14 (36.83-43.28)
43.98 (39.21-48.34)
0.014
5 (3-9)
3 (2-4)
0.037
55.9 (51.2-60.2)
57.7 (52.7-62.4)
0.222
31.0 (27.7-38.8)
39.3 (33.1-45.7)
0.007
Remnant pancreatic volume, mL
10.3 (5.8-15.3)
15.4 (9.6-23.8)
0.007
eFRPV, mL·HU
32.8 (17.1-46.6)
60.6(32.2-104.6)
0.002
44.6 (19.9-71.6)
69.7 (57.9-78.4)
0.003
10 (3-12)
3 (2-6)
0.003
CONUT score
Preoperative CT findings
CT attenuation value of the liver, HU
CT attenuation value
of the remnant pancreas, HU
Histopathological findings
Pancreatic acinar cell density, %
Fibrotic score
31
Data are expressed as median with interquartile range for continuous data or as number and
percentage for categorical data.
Abbreviations: NAFLD, nonalcoholic fatty liver disease; CONUT, controlling nutritional status;
MPD, main pancreatic duct; CT, computed tomography; HU, Hounsfield units; eFRPV, estimated
functional remnant pancreatic volume
32
Table 2. Multivariate analysis of preoperative evaluable factors
Factors
Odd’s ratio
95% confidence interval
P-value
Neoadjuvant chemotherapy
3.98
0.74-21.40
0.108
Prevalence of liver dysfunction
10.70
1.15-98.80
0.037
Creatinine
0.19
0.01-2.79
0.224
eFPRV ≤ 47 mL·HU
6.73
1.70-26.70
0.007
Abbreviations: eFRPV, estimated functional remnant pancreatic volume
33
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