Updated Alternative Fistula Risk Score (ua-FRS) to Include Minimally Invasive Pancreatoduodenectomy

Abstract

Objective: The aim of the study was to validate and optimize the alternative Fistula Risk Score (a-FRS) for patients undergoing minimally invasive pancreatoduodenectomy (MIPD) in a large pan-European cohort. 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 (International Study Group on Pancreatic Surgery 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 (odds ratio 4.6, 95 confidence interval [CI] 2.8–7.6) and male sex (odds ratio 1.9, 95 CI 1.4–2.7) were identified as important risk factors for POPF in MIPD. The updated a-FRS, consisting of body mass index, 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 and open pancreatoduodenectomy. Conclusions: The updated a-FRS (www.pancreascalculator.com) now includes male sex as a risk factor and is validated for both MIPD and open pancreatoduodenectomy. The increased risk of POPF in laparoscopic MIPD was associated with single-row pancreatojejunostomy, which should therefore be discouraged.

Kiguchi Method, A Novel Simplified Technique For Pancreaticojejunostomy In Minimally Invasive Pancreaticoduodenectomy, Significantly Reduces Postoperative Pancreatic Fistula Rate In Patients With A Soft Pancreatic Texture 

“…Among the patients without POPF, the hospital stay was signi cantly shorter in all patients undergoing MIPD than in all patients undergoing OPD, highlighting the bene t of MIPD regardless of the speci c PJ method used. The multivariate analysis also revealed that male sex was a signi cant risk factor for POPF, in agreement with studies showing that male sex is a risk factors for POPF not only in OPD but also in MIPD [43,44]. However, the underlying cause requires further investigation.…”

Transatlantic registries of pancreatic surgery in the United States of America, Germany, the Netherlands, and Sweden: Comparing design, variables, patients, treatment strategies, and outcomes

“…Interestingly, various parameters that are important predictors of outcomes in pancreatic surgery (eg, pancreatic duct size, pancreatic gland texture, postpancreatectomy hemorrhage, resection margin) were not registered in 1 or more registries. 12,13 The differences are partly because of the various development strategies of the registries. In 2004, the American College of Surgeons National Surgical Quality Improvement Program for pancreatic surgery was built from the initial Veterans Affairs National Surgical Quality Improvement Program (NSQIP), in which data on major operations were captured with the aim to provide feedback and reduce postoperative morbidity and mortality.…”

Risk factors for pancreatic fistula grade C after pancreatoduodenectomy: A large prospective, multicenter Japan‐Taiwan collaboration study

“…Soft pancreas, which was associated with development of Grade C POPF in this study, has been widely recognized as a risk factor for CR-POPF in previous studies. [7][8][9][10]16,17 Soft pancreas is susceptible to ischemia and injury and is vulnerable to being torn through during suturing. Additionally, exocrine function is generally preserved in soft pancreas, resulting in increased secretion of pancreatic juice, rich in T A B L E 3 Independent risk factors of Grade C POPF on multivariate analysis for prediction of Grade C POPF proteolytic enzymes.…”

“…Increased BMI has been widely recognized to be associated with CR-POPF. [9][10][11]19,20 This can be attributed to the association between elevated BMI and fatty pancreatic parenchyma, as well as the impact of obesity on wound healing. 19,20 The current cohort included Japanese and Taiwanese and they tend to have less BMI than those of Western nations (BMI ≥ 25.0 kg/ m 2 n = 512 (18.5%), BMI ≥ 30.0 kg/m 2 n = 62 (2.2%)).…”

“…[4][5][6][7][8] Several previous studies have identified risk factors associated with clinically relevant (CR-) POPF, including Grades B and C POPFs, and several risk models have been suggested. [9][10][11] Among these reports, Fistula Risk Score (FRS) reported by Callery, et al 9 and updated alternative (ua-) FRS reported by Mungroop, et al 10 are widely accepted and used for prediction of CR-POPF after PD. Studies that identified risk factors and specifically focusing on Grade C POPF have been more limited, however, because the infrequent occurrence of Grade C POPF has hindered analysis of the risk factors.…”