Alternative Fistula Risk Score for Pancreatoduodenectomy (a-FRS): Design and International External Validation
Postoperative pancreatic fistula (POPF) remain one of the most threatening complications after pancreatoduodenectomy (PD). The Fistula Risk Score (FRS, Callery - 2013) predicts POPF based on gland texture, pancreatic duct diameter, intraoperative blood loss, and pathology. Some have argued that a FRS without blood loss could be preferred. First, intraoperative blood loss was not a significant factor at recent external validation (Shubert - 2015, Grendal - 2017) Second, it is currently not registered in several audits, for example, the National Surgical Quality Improvement Program (US-NSQIP) and the Dutch Pancreatic Cancer Audit (DPCA). Third, blood loss depends on surgical quality, and is therefore not a suitable prognostic factor for adjusting POPF-risk for benchmarking. Fourth, several studies have argued that estimation of blood loss is unreliable and inaccurate, and this metric therefore should not be used to judge physician performance or patient outcomes. Finally, in future patients this factor may be even less predictive for POPF, because for example minimally-invasive PD leads to less blood loss but similar rates of pancreatic fistula. Aim of this study was to develop a fistula risk score without blood loss.
Research authors: Mungroop TH, van Rijssen LB, van Klaveren D, Smits FJ, van Woerden V, Linnemann RJ, de Pastena M, Klompmaker S, Marchegiani G, Ecker B, van Dieren S, Bonsing B, Busch OR, van Dam RM, Erdmann J, van Eijck CH, Gerhards MF, van Goor H, van der Harst E, de Hingh IG, de Jong KP, Kazemier G, Luyer M, Shamali A, Barbaro S, Armstrong T, Takhar A, Hamady Z, Klaase J, Lips DJ, Molenaar IQ, Nieuwenhuijs VB, Rupert C, van Santvoort HC, Scheepers JJ, van der Schelling GP, Bassi M, Vollmer CM, Steyerberg EW, Abu Hilal M, Groot Koerkamp B, Besselink MG
Details Formula Study characteristics Files & References
Model author
Model ID
Revision date
MeSH terms
  • Pancreaticoduodenectomy
  • Complication, Postoperative
  • Pancreatic Fistula
  • Risk Assessment
  • Clinical Prediction Rule
  • Model type
    Logistic regression (Calculation)
    No Formula defined yet
    Condition Formula

    Additional information

    The a-FRS was developed in two cohorts: the Dutch Pancreatic Cancer Audit (18 centers) and the University Hospital Southampton NHS. Primary outcome was grade B/C POPF according the 2005 ISGPS definition. A prediction model was proposed and externally validated in two independent databases (University Hospital of Verona and University Hospital of Pennsylvania). The a-FRS was also compared to the original-FRS.


    Study Population

    Total population size: 2830

    Additional characteristics

    No additional characteristics defined
    Alternative Fistula Risk Score for Pancreatoduodenectomy (a-FRS): Design and International External Validation
    Refer to Intended Use for instructions before use
    Evidencio B.V., Irenesingel 19, 7481 GJ, Haaksbergen, the Netherlands

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    Supporting Publications

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    Calculated risk of postoperative pancreatic fistula:

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    Outcome stratification

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    Result interpretation


    How this model should be used: 
    This validated fistula risk model allows for prediction of POPF during surgery based on pancreatic texture, pancreatic duct diameter, and BMI. 

    Model performance: 
    Discrimination of the model was good with an AUC of 0.75 (95% CI: 0.71-0.78) after internal validation, 0.78 [0.74-0.82] after external validation. The predictive capacity of a-FRS was comparable with the original-FRS, both for the 2005 definition (AUC 0.78 vs. 0.75, P = 0.03), and 2016 definition (AUC 0.72 vs. 0.70, P = 0.05). 

    Mungroop et al, Annals of Surgery, 2017.

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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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