Validation of a computed tomography-based model for early prediction of postpancreatectomy hemorrhage risk

Identification of early predictors of postoperative pancreatic fistula (POPF) related postpancreatectomy hemorrhage (PPH) on contrast-enhanced computed tomography (CT) may help tailor management after pancreaticoduodenectomy (PD). However, no model has been validated yet.

A bicentric analysis of consecutive PDs performed between 2017 and 2022 was conducted. The recently reported CT-based prediction score (CTS) was externally validated. Sensitivity refinements were proposed using a modified CTS, which was internally (development cohort [n = 182]) and externally (validation cohort [n = 62]) validated. Bootstrap-corrected areas under the curve (AUCs), sensitivity, and positive predictive value (PPV) were used to evaluate and compare the 2 scores.

A total of 244 patients (55.1% were women; median age, 68 years [IQR, 58.0-75.0]; clinically relevant (cr)-POPF, 25.4%; cr-PPH, 13.9%) were included. CTS accurately predicted the cr-PPH, with an AUC of 0.83 (1000 bootstrap 95% CI, 0.76-0.89). The modified CTS, which is available online (https://stylianostzedakis.shinyapps.io/pph_risk_calculator/), included CTS with 2 supplementary variables selected from a multivariable backward stepwise regression: perianastomotic air bubbles, posterosuperior pancreaticojejunal (PJ) anastomosis collection, posterior PJ defect, PJ collection in contact with a hepatic or gastroduodenal artery stump, and arterial wall irregularities. When compared with the CTS, although modified CTS AUCs were similar in the validation cohort (0.81 [95% CI, 0.62-0.95] vs 0.87 [95% CI, 0.56-0.96]; DeLong P = .7), sensitivity and PPV for early PPH detection were significantly higher (0.82 [95% CI, 0.75-0.92] vs 0.71 [95% CI, 0.35-0.75] and 0.95 [95% CI, 0.83-0.99] vs 0.33 [95% CI, 0.12-0.62]; McNemar P = .03).

With a robust prediction model, early CT scan after PD seems a valid tool for the early identification of high-risk patients with cr-PPH.