Updated Alternative Fistula Risk Score (ua-FRS) to include Minimally-Invasi

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Updated Alternative Fistula Risk Score (ua-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

Public
Surgery
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Probability of postoperative pancreatic fistula (POPF):

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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) PMID: 30829699 DOI: 10.1097/SLA.0000000000003234

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Additional information

Details

Model author

T.H. Mungroop MD MSc

Model ID

1408

Version

1.47

Revision date

2021-01-05

Specialty

Surgery

Model type

Logistic regression ^{(Calculation)}

MeSH terms

Pancreas

Pancreatoduodenectomy

Robotic Surgical Procedure

Pancreatic Cancer

Laparoscopic Surgery

Rating

Status

Public

Formula
No Formula defined yet

Condition	Formula

Study characteristics

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
Number of patients who developed POPF after MIPD	No	750
Type of MIPD	Laparoscopic	543
Type of MIPD	robot-assisted	258
Type of MIPD	Hybrid	151

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