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Multicenter Study
. 2025 Aug;39(8):4863-4871.
doi: 10.1007/s00464-025-11872-5. Epub 2025 Jun 20.

International validation of the distal pancreatectomy fistula risk score: evaluation in minimally invasive and open surgery

Philip C Müller  1 , Suna Erdem  2 , Christoph Kuemmerli  2 , Felix Nickel  3 , O H Fiete Gehrisch  3 , Faik G Uzunoglu  3 , Amelie Hannoschöck  2 , Noa L E Aegerter  2 , Caroline Berchtold  2 , Jan Philipp Jonas  4 , Michael C Frey  4 , Beat Moeckli  5 , Christian Toso  5 , Julia Mühlhäusser  6   7 , Jörn-Markus Gass  6   7 , Riccardo Pellegrini  8 , Umberto Cillo  8 , Giovanni Marchegiani  8 , Cristiano Guidetti  9 , Fabrizio Di Benedetto  9 , Anna S Wenning  10 , Beat Gloor  10 , Kim C Wagner  11 , Karl J Oldhafer  11 , Christoph Tschuor  12 , Paul Suno Krohn  12 , Stefan K Burgdorf  12 , Alberto García-Picazo  13 , Patricia Sánchez-Velázquez  13 , Didier Roulin  14   15 , John B Martinie  14 , Thilo Hackert  3 , Beat P Müller  2 , Adrian T Billeter  2
Affiliations
Multicenter Study

International validation of the distal pancreatectomy fistula risk score: evaluation in minimally invasive and open surgery

Philip C Müller et al. Surg Endosc. 2025 Aug.

Abstract

Background: Postoperative pancreatic fistula (POPF) remains the most severe complication following distal pancreatectomy (DP). The preoperative distal fistula risk score (D-FRS) was introduced to predict the POPF risk. The aim of this study was to externally validate the D-FRS in an international expert center cohort.

Methods: This international, multicenter, retrospective cohort study included open and minimally invasive DP for benign and malignant lesions performed from 01/2014 until 12/2023 in 12 centres from 6 countries, that each performed more than 50 pancreatectomies annually. The D-FRS was calculated from pancreatic thickness and duct size. Predicted and actual POPF were compared using sensitivity, specificity and area under the curve (AUC).

Results: A total of 778 patients underwent DP of whom 284 (39%) underwent robotic, 278 (38%) open and 165 (23%) laparoscopic DP. The rate of POPF was 32%. The sensitivity, specificity and AUC of the D-FRS for the overall cohort was 32%, 63% and 48% (95% CI 44-51%), respectively. The AUC for open, laparoscopic and robotic DP was 54% (48-60%), 47% (39-55%) and 45% (39-50%), respectively. For neoadjuvant therapy naïve patients the AUC was 52.3%. On multivariate analysis POPF was associated with body mass index (odds ratio 1.04 (95% CI 1.01-1.07)), protective factors were neoadjuvant therapy (OR 0.54 (0.22-0.94)) and the robotic approach (OR 0.64 (0.42-0.97)).

Conclusions: The preoperative D-FRS showed insufficient discrimination to identify patients who develop POPF after DP irrespective of the surgical approach. Novel preoperative POPF risk scores are needed, considering the standard minimally invasive approach and the widespread use of neoadjuvant therapy.

Keywords: Complications; Distal pancreatectomy; Outcome research; Pancreatic surgery; Robotic surgery.

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Conflict of interest statement

Declarations. Disclosures: Philip Müller, Suna Erdem, Christoph Kuemmerli, Felix Nickel, O. H. Fiete Gehrisch, Faik Uzunoglu, Amelie Hannoschöck, Noa Aegerter, Caroline Berchtold, Jan Philipp Jonas, Michael Frey, Beat Moeckli, Christian Toso, Julia Mühlhäusser, Markus Gass, Riccardo Pellegrini, Umberto Cillo, Giovanni Marchegiani, Cristiano Guidetti, Fabrizio Di Benedetto, Anna Wenning, Beat Gloor, Kim Wagner, Karl Oldhafer, Christoph Tschuor, Paul Suno Krohn, Stefan Burgdorf, Alberto García Picazo, Patricia Sánchez-Velázquez, Didier Roulin, John Martinie, Thilo Hackert, Beat Müller and Adrian Billeter, have no conflicts of interest or financial ties to disclose. Ethical approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Ethical approval from the institutional review board of the University of Basel was obtained (BASEC ID 2023–02081).

References

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