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
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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

Addendum: Risk categories: low risk <5%, intermediate risk 5-20%, high risk >20% (based on: Mungroop – Ann Surg 2019 May, 269(5): 937-943).

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