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. 2023 Dec 1;6(12):e2346113.
doi: 10.1001/jamanetworkopen.2023.46113.

Development and Validation of a Model for Postpancreatectomy Hemorrhage Risk

Emrullah Birgin  1   2 , Sebastian Hempel  3 , Alina Reeg  1 , Florian Oehme  3 , Annika Schnizer  1 , Johann S Rink  4 , Matthias F Froelich  4 , Svetlana Hetjens  5 , Verena Plodeck  6 , Heiner Nebelung  6 , Schaima Abdelhadi  1 , Mohammad Rahbari  1 , Patrick Téoule  1 , Erik Rasbach  1 , Christoph Reissfelder  1 , Jürgen Weitz  3 , Stefan O Schoenberg  4 , Marius Distler  3 , Nuh N Rahbari  1   2
Affiliations

Development and Validation of a Model for Postpancreatectomy Hemorrhage Risk

Emrullah Birgin et al. JAMA Netw Open. .

Abstract

Importance: Postpancreatectomy hemorrhage (PPH) due to postoperative pancreatic fistula (POPF) is a life-threatening complication after pancreatoduodenectomy. However, there is no prediction tool for early identification of patients at high risk of late PPH.

Objective: To develop and validate a prediction model for PPH.

Design, setting, and participants: This retrospective prognostic study included consecutive patients with clinically relevant POPF who underwent pancreatoduodenectomy from January 1, 2009, to May 20, 2023, at the University Hospital Mannheim (derivation cohort), and from January 1, 2012, to May 31, 2022, at the University Hospital Dresden (validation cohort). Data analysis was performed from May 30 to July 29, 2023.

Exposure: Clinical and radiologic features of PPH.

Main outcomes and measures: Accuracy of a predictive risk score of PPH. A multivariate prediction model-the hemorrhage risk score (HRS)-was established in the derivation cohort (n = 139) and validated in the validation cohort (n = 154).

Results: A total of 293 patients (187 [64%] men; median age, 69 [IQR, 60-76] years) were included. The HRS comprised 4 variables with associations: sentinel bleeding (odds ratio [OR], 35.10; 95% CI, 5.58-221.00; P < .001), drain fluid culture positive for Candida species (OR, 14.40; 95% CI, 2.24-92.20; P < .001), and radiologic proof of rim enhancement of (OR, 12.00; 95% CI, 2.08-69.50; P = .006) or gas within (OR, 12.10; 95% CI, 2.22-65.50; P = .004) a peripancreatic fluid collection. Two risk categories were identified with patients at low risk (0-1 points) and high risk (≥2 points) to develop PPH. Patients with PPH were predicted accurately in the derivation cohort (C index, 0.97) and validation cohort (C index 0.83). The need for more invasive PPH management (74% vs 34%; P < .001) and severe complications (49% vs 23%; P < .001) were more frequent in high-risk patients compared with low-risk patients.

Conclusions and relevance: In this retrospective prognostic study, a robust prediction model for PPH was developed and validated. This tool may facilitate early identification of patients at high risk for PPH.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Schoenberg reported working in collaboration with Siemens Healthineers without compensation. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Patient Flowchart
Figure 2.
Figure 2.. Receiver Operating Characteristic Curves in the Derivation and Validation Cohorts
A, The receiver operating characteristic curve analysis of the hemorrhage risk score to predict postpancreatectomy hemorrhage in the derivation cohort is displayed. An area under the curve (AUC) of 0.97 (95% CI, 0.94-0.99) was calculated for the scoring model from 0 to 4 points. The AUC of the risk categorization model (low vs high risk) yielded a value of 0.93 (95% CI, 0.87-0.98). B, In the validation cohort, an AUC of 0.83 (95% CI, 0.76-0.90) was calculated for the scoring model, and an AUC of 0.77 (95% CI, 0.70-0.84) for the risk categorization model (low vs high risk).
Figure 3.
Figure 3.. Postpancreatectomy Hemorrhage Rate in the Derivation and Validation Cohorts With Regard to the Postpancreatectomy Hemorrhage Risk Score and Risk Classification
See this image and copyright information in PMC

Comment in

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