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
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Calculated risk of postoperative pancreatic fistula:

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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). 

Source: 
Mungroop et al, Annals of Surgery, 2017.

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