Development and external validation of DISPAIR fistula risk score for clinically relevant postoperative pancreatic fistula risk after distal pancreatectomy

Abstract

Background Highly utilized risk scores for clinically relevant postoperative pancreatic fistula (CR-POPF) have guided clinical decision-making in pancreatoduodenectomy. However, none has been successfully developed for distal pancreatectomy. This study aimed to develop and validate a new fistula risk score for distal pancreatectomy. Methods Patients undergoing distal pancreatectomy at Helsinki University Hospital, Finland from 2013 to 2021, and at Karolinska University Hospital, Sweden, from 2010 to 2020, were included retrospectively. The outcome was CR-POPF, according to the 2016 International Study Group of Pancreatic Surgery definition. Preoperative clinical demographics and radiological parameters such as pancreatic thickness and duct diameter were measured. A logistic regression model was developed, internally validated with bootstrapping, and the performance assessed in an external validation cohort. Results Of 668 patients from Helsinki (266) and Stockholm (402), 173 (25.9 per cent) developed CR-POPF. The final model consisted of three variables assessed before surgery: transection site (neck versus body/tail), pancreatic thickness at transection site, and diabetes. The model had an area under the receiver operating characteristic curve (AUROC) of 0.904 (95 per cent c.i. 0.855 to 0.949) after internal validation, and 0.798 (0.748 to 0.848) after external validation. The calibration slope and intercept on external validation were 0.719 and 0.192 respectively. Four risk groups were defined in the validation cohort for clinical applicability: low (below 5 per cent), moderate (at least 5 but below 30 per cent), high (at least 30 but below 75 per cent), and extreme (75 per cent or more). The incidences in these groups were 8.7 per cent (11 of 126), 22.0 per cent (36 of 164), 63 per cent (57 of 91), and 81 per cent (17 of 21) respectively. Conclusion The DISPAIR score after distal pancreatectomy may guide decision-making and allow a risk-adjusted outcome comparison for CR-POPF.

Staple line lockstitch reinforcement decreases clinically relevant pancreatic fistula following distal pancreatectomy: Results of a propensity score matched retrospective analysis

“…Several studies have identified risk factors related to POPF occurrence after DP. (7,8). Effective closure of pancreatic remnants of irregular thickness is crucial for fistula prevention.…”

“…Postoperative pancreatic fistula (POPF) remains the major complication after DP and can potentially cause further complications, such as abdominal fluid collection, severe intra-abdominal infection and hemorrhage. Preventing POPF via effective pancreatic remnant closure remains challenging, and no consensus on the optimal surgical technique has been established (1,(5)(6)(7)(8).…”

Acute PresentatiOn of coLorectaL cancer ‐ an internatiOnal snapshot (APOLLO): Protocol for a prospective, multicentre cohort study

“…Area under the receiver operating characteristic curve will be used to assess discrimination. Validation of the model will be performed as the methods of Bonsdorff et al [ 16 ]. Statistical analysis will be completed using R (R Foundation Statistical Program).…”

Postoperative pancreatic fistula after distal pancreatectomy: pancreatic thickness and duct size as the only denominators?

“…The clinical relevance of pancreas thickness in risk assessment of POPF after DP should be underlined. While intuitively meaningful, this was rarely reported in previous published studies (2,8,9). Such a point raises questions regarding the appropriate definition of a thick pancreas and which transection technique should be preferred (10).…”

“…The authors should be commended for this study bringing the first validated risk score for CR-POPF after DP, the so-called D-FRS. Recently, another similar score has been published but without external validation ( 2 ). Such a clinical risk score is of paramount importance for preoperative risk assessment and patient information.…”