Updated Alternative Fistula Risk Score (a-FRS) to include Minimally-Invasive Pancreatoduodenectomy: Pan-European Validation
OBJECTIVE: To validate and optimize the alternative Fistula Risk Score (a-FRS) for patients undergoing minimally invasive pancreatoduodenectomy (MIPD) in a large pan-European cohort.
Research authors: Mungroop TH, Klompmaker S, Wellner UF, Steyerberg EW, Coratti A, D’Hondt M, de Pastena M, Dokmak S, Khatov I, Saint-Marc O, Wittel U, Hilal MA, Fuks D, Poves I, Keck T, Boggi U, Besselink MG
Details Custom formula Study characteristics Files & References
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Model author
Model ID
1408
Version
1.36
Revision date
2019-02-20
Specialty
MeSH terms
  • Pancreas
  • Pancreatoduodenectomy
  • Robotic Surgical Procedure
  • Pancreatic Cancer
  • Laparoscopic Surgery
  • Model type
    Logistic regression (Calculation)
    Status
    public
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    Formula
    No Formula defined yet
    Condition Formula

    Additional information

    Patient population:
    This is a post-hoc analysis of a pan-European multicenter cohort of 952 consecutive patients undergoing MIPD (543 laparoscopic, 258 robot-assisted, 151 hybrid) in 26 centers from 7 countries between 2007 and 2017. Adult patients with an indication for elective MIPD (laparoscopic, robot-assisted, or hybrid) were included. No other exclusion criteria were applied.

    Primary outcome measure: 
    The primary outcome of the study was grade B/C POPF (according to the 2005 International Study Group on Pancreatic Surgery [ISGPS] classification) within 30 days postoperatively.

    Study Population

    Total population size: 952

    Categorical characteristics

    Name Subset / Group Nr. of patients
    Number of patients who developed POPF after MIPD Yes 202
    No 750
    Type of MIPD Laparoscopic 543
    robot-assisted 258
    Hybrid 151

    Related files

    Supporting Publications

    Probability of postoperative pancreatic fistula (POPF):
    ...

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    Result
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    Probability of postoperative pancreatic fistula (POPF):

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    Outcome stratification

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    Conditional information

    Result interpretation

    BACKGROUND: MIPD may be associated with an increased risk of postoperative pancreatic fistula (POPF). The a-FRS could allow for risk-adjusted comparisons in research and improve preventive strategies for high-risk patients. The a-FRS, however, has not yet been validated specifically for laparoscopic, robot-assisted and hybrid MIPD.

    METHODS: A validation study was performed in a pan-European cohort of 952 consecutive patients undergoing MIPD (543 laparoscopic, 258 robot-assisted, 151 hybrid) in 26 centers from 7 countries between 2007 and 2017. The primary outcome was POPF (ISGPS grade B/C). Model performance was assessed using the area under the receiver-operating-curve (AUC; discrimination) and calibration plots. Validation included univariable screening for clinical variables that could improve performance.

    RESULTS: Overall, 202 of 952 patients (21%) developed POPF after MIPD. Before adjustment, the original a-FRS performed moderately (AUC 0.68) and calibration was inadequate with systematic underestimation of the POPF risk. Single-row pancreatojejunostomy (OR 4.6, 95-CI 2.8-7.6) and male sex (OR 1.8, 95-CI 1.4-2.7) were identified as important risk factors for POPF in MIPD. The updated a-FRS, consisting of BMI, pancreatic texture, duct size, and male sex, showed good discrimination (AUC 0.75, 95-CI 0.71-0.79) and adequate calibration. Performance was adequate for laparoscopic, robot-assisted, and hybrid MIPD as well as open pancreatoduodenectomy (OPD).

    CONCLUSIONS: The updated a-FRS (www.pancreascalculator.com) now includes male sex as a risk factor and is validated for both MIPD and OPD. The increased risk of POPF in MIPD was related to single-row pancreatojejunostomy, which should therefore be discouraged.

    REFERENCES: Mungroop TH, Klompmaker S, Wellner UF, et al. Updated alternative fistula risk score (ua-FRS) to include minimally invasive pancreatoduodenectomy: pan-European validation. Annals of Surgery (2019) - Article in press. 

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    Calculations alone should never dictate patient care, and are no substitute for professional judgement. See our full disclaimer.

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