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Multicenter Study
. 2021 Feb 1;273(2):334-340.
doi: 10.1097/SLA.0000000000003234.

Updated Alternative Fistula Risk Score (ua-FRS) to Include Minimally Invasive Pancreatoduodenectomy: Pan-European Validation

Timothy H Mungroop  1 , Sjors Klompmaker  1 , Ulrich F Wellner  2   3 , Ewout W Steyerberg  4 , Andrea Coratti  5 , Mathieu D'Hondt  6 , Matteo de Pastena  7 , Safi Dokmak  8 , Igor Khatkov  9 , Olivier Saint-Marc  10 , Uwe Wittel  11 , Mohammed Abu Hilal  12 , David Fuks  13 , Ignasi Poves  14 , Tobias Keck  2   3 , Ugo Boggi  15 , Marc G Besselink  1 ; European Consortium on Minimally Invasive Pancreatic Surgery (E-MIPS)
Affiliations
Multicenter Study

Updated Alternative Fistula Risk Score (ua-FRS) to Include Minimally Invasive Pancreatoduodenectomy: Pan-European Validation

Timothy H Mungroop et al. Ann Surg. .

Erratum in

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.

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Conflict of interest statement

The authors report no conflicts of interests.

References

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    1. Mungroop TH, Van Rijssen LB, Van Klaveren D, et al. Alternative Fistula Risk Score for pancreatoduodenectomy (a-FRS). Ann Surg 2017; Dec 12. Epub ahead of print.
    1. Callery MP, Pratt WB, Kent TS, et al. A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy. J Am Coll Surg 2013; 216:1–14.

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