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
Details Formula Study characteristics Files & References
Model author
Model ID
Revision date
MeSH terms
  • Pancreas
  • Pancreatoduodenectomy
  • Robotic Surgical Procedure
  • Pancreatic Cancer
  • Laparoscopic Surgery
  • Model type
    Logistic regression (Calculation)
    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
    Evidencio B.V.
    Refer to Intended Use for instructions before use
    Evidencio B.V., Irenesingel 19, 7481 GJ, Haaksbergen, the Netherlands

    Related files

    Supporting Publications

    Probability of postoperative pancreatic fistula (POPF):

    {{ resultSubheader }}

    {{ model.survival.PITTitle }}

    {{ model.survival.YNETitle }}

    Notes are only visible in the result download and will not be saved by Evidencio

    Probability of postoperative pancreatic fistula (POPF):

    {{ resultSubheader }}
    {{ table.title }}
    {{ row }}
    {{ chart.title }}

    Outcome stratification

    Result interval {{ additionalResult.min }} to {{ additionalResult.max }}

    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. 

    {{ file.classification }}

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

    Please enter a comment of rating
    Comments are visible to anyone

    Model feedback

    No feedback yet 1 Comment {{ model.comments.length }} Comments
    Not rated | On {{ comment.created_at }} {{ comment.user.username }} a no longer registered author wrote:

    Please sign in to enable Evidencio print features

    In order to use the Evidencio print features, you need to be logged in.
    If you don't have an Evidencio Community Account you can create your free personal account at:


    Printed results - Examples {{ new Date().toLocaleString() }}

    Evidencio Community Account Benefits

    With an Evidencio Community account you can:

    • Create and publish your own prediction models.
    • Share your prediction models with your colleagues, research group, organization or the world.
    • Review and provide feedback on models that have been shared with you.
    • Validate your models and validate models from other users.
    • Find models based on Title, Keyword, Author, Institute, or MeSH classification.
    • Use and save prediction models and their data.
    • Use patient specific protocols and guidelines based on sequential models and decision trees.
    • Stay up-to-date with new models in your field as they are published.
    • Create your own lists of favorite models and topics.
    A personal Evidencio account is free, with no strings attached! Join us and help create clarity, transparency, and efficiency in the creation, validation, and use of medical prediction models.

    Disclaimer: Calculations alone should never dictate patient care, and are no substitute for professional judgement.