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Before sentinel bleeding: early prediction of postpancreatectomy hemorrhage (PPH) with a CT-based scoring system

  • Hepatobiliary-Pancreas
  • Published:
European Radiology Aims and scope Submit manuscript

Abstract

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.

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Abbreviations

AUC:

Area under the curve

CI:

Confidence Interval

ICC:

Intraclass correlation coefficient

IR:

Interventional radiology

ISGPF:

International Study Group of Pancreatic Surgery

PD:

Pancreaticoduodenectomy

PJ:

Pancreaticojejunostomy

POPF:

Postoperative pancreatic fistula

PPFH:

Postpancreatectomy pancreatic fistula–associated hemorrhage

PPH:

Postpancreatectomy hemorrhage

ROC:

Receiver operating characteristics

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Funding

The authors state that this work has not received any funding.

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Author notes

  1. D. P. and D. T. contributed equally to this work.

Authors and Affiliations

  1. Radiology Unit, San Raffaele Scientific Institute, via Olgettina 60, 20132, Milan, Italy

    Diego Palumbo, Simone Gusmini, Giorgia Guazzarotti, Roberta Cao & Francesco De Cobelli

  2. San Raffaele Vita Salute University, Milan, Italy

    Diego Palumbo, Stefano Partelli, Roberta Cao, Stefano Crippa, Massimo Falconi & Francesco De Cobelli

  3. Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy

    Domenico Tamburrino, Stefano Partelli, Stefano Crippa & Massimo Falconi

  4. La Sapienza University, Rome, Italy

    Domenico Tamburrino

Authors
  1. Diego Palumbo
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  2. Domenico Tamburrino
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  9. Francesco De Cobelli
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Corresponding author

Correspondence to Diego Palumbo.

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Guarantor

The scientific guarantor of this publication is Francesco De Cobelli, MD (Radiology Department director, Ospedale San Raffaele, Milano, Italy)

Conflict of interest

The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Procedure specific written informed consent covering retrospective studies was obtained from all subjects (patients) in this study.

Ethical approval

Institutional Review Board approval was obtained.

Methodology

• Retrospective

• Case-control study

• Performed at one institution

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Palumbo, D., Tamburrino, D., Partelli, S. et al. Before sentinel bleeding: early prediction of postpancreatectomy hemorrhage (PPH) with a CT-based scoring system. Eur Radiol 31, 6879–6888 (2021). https://doi.org/10.1007/s00330-021-07788-y

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  • DOI: https://doi.org/10.1007/s00330-021-07788-y

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