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Before sentinel bleeding: early prediction of postpancreatectomy hemorrhage (PPH) with a CT-based scoring system
Diego Palumbo1,2, Domenico Tamburrino3,4, Stefano Partelli5,3
1Radiology Unit, San Raffaele Scientific Institute, via Olgettina 60, 20132, Milan, Italy. palumbo.diego@hsr.it.
Insights
Postpancreatectomy hemorrhage (PPFH) risk after pancreaticoduodenectomy (PD) can be predicted using CT scans. Early identification of specific CT findings aids in proactive patient management and prevention.
Area of Science:
- Abdominal Radiology
- Surgical Oncology
- Gastroenterology
Background:
- Clinically significant pancreatic fistula (POPF) is a known risk factor for severe postpancreatectomy hemorrhage (PPFH) after pancreaticoduodenectomy (PD).
- Predicting PPFH remains challenging, impacting patient management strategies.
Purpose of the Study:
- To evaluate the effectiveness of contrast-enhanced CT scans in the early prediction of PPFH following PD.
- To identify specific CT findings indicative of PPFH risk.
Main Methods:
- Retrospective analysis of consecutive patients undergoing PD between January 2013 and May 2019.
- Inclusion criteria: patients evaluated with contrast-enhanced CT for suspected POPF.
- CT findings assessed: perianastomotic fluid collections, air bubbles, and pancreaticojejunostomy (PJ) integrity (dehiscence/defect).
Main Results:
- Out of 166 enrolled patients, 33 (19.9%) experienced PPFH.
- Multivariable analysis linked PPFH to postoperative CT evidence of fluid collections (p=0.046), air bubbles (p=0.046), and posterior PJ defect (p<0.001).
- A 4-point prediction score (AUC: 0.904) was developed, with scores ≥3 significantly increasing PPFH risk (OR=45.6).
Conclusions:
- Postoperative contrast-enhanced CT scans enable early risk stratification for PPFH.
- A practical CT-based 4-point scoring system aids in identifying patients at high risk.
- CT facilitates a shift from passive observation to proactive management of PPFH.
Objectives:
Clinically significant pancreatic fistula (POPF) has been established as a well-known risk factor for late and severe postpancreatectomy hemorrhage after pancreaticoduodenectomy (PD) (postpancreatectomy pancreatic fistula-associated hemorrhage [PPFH]). Our aim was to assess whether contrast-enhanced CT scan after PD is an effective tool for early prediction of PPFH.
Methods:
From a prospectively acquired database, all consecutive patients who underwent PD between January 2013 and May 2019 were identified; within this database, all patients who were evaluated, for clinical suspicion of POPF, with at least one contrast-enhanced CT scan examination, were enrolled in this retrospective study. The selected CT findings included perianastomotic fluid collections and air bubbles; pancreaticojejunostomy (PJ) was analyzed in terms of dehiscence and defect.
Results:
One hundred seventy-eight out of 953 PD patients (18.7%) suffered from clinically significant POPF; after exclusions, 166 patients were enrolled. Among this subset, 33 patients (19.9%) had at least one PPFH episode. In multivariable analysis, PPFH was associated with postoperative CT evidence of fluid collections (p = 0.046), air bubbles (p = 0.046), and posterior PJ defect (p < 0.001). Based on these findings, a practical 4-point prediction score was developed (AUC: 0.904, Se: 76%, Sp: 93.8%): patients with a score ≥ 3 demonstrated a significantly higher risk of PPFH development (OR = 45.6, 95% CI: 13.0-159.3).
Conclusions:
Postoperative CT scan permits early stratification of PPFH risk, thus providing an actual aid for patients' management.
Key Points:
• Postpancreatectomy hemorrhage (PPH) is a dramatic, clinically unpredictable occurrence. • After pancreaticoduodenectomy (PD), early identification of posterior pancreaticojejunostomy defect, perianastomotic air bubbles, and retroperitoneal fluid collections enables effective PPH risk stratification by means of a practical CT-based 4-point scoring system. • CT scan after PD allows a paradigm shift in the management PPH, from a conventional "wait and see" approach, to a more proactive one that relies on early anticipation and timely prevention.
