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Clinical Risk Score to Predict Pancreatic Fistula after Pancreatoduodenectomy: Independent External Validation for Open and Laparoscopic Approaches

Published on Sep 1, 2015in Journal of The American College of Surgeons4.45
· DOI :10.1016/j.jamcollsurg.2015.05.011
Christopher R. Shubert9
Estimated H-index: 9
(Mayo Clinic),
Amy E. Wagie15
Estimated H-index: 15
(Mayo Clinic)
+ 6 AuthorsMichael L. Kendrick45
Estimated H-index: 45
(Mayo Clinic)
Abstract
Background A clinical risk score for pancreatic fistula (CRS-PF) was recently reported to predict postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD). An independent external validation has not been performed. Our hypothesis was that CRS-PF predicts POPF after both laparoscopic and open PD. Study Design The CRS-PF was calculated from a retrospective review of patients undergoing PD from January 2007 to February 2014. Postoperative pancreatic fistula was graded using International Study Group of Pancreatic Fistula criteria. Grade B and C leaks were defined as clinically significant. Performance was measured based on sensitivity, specificity, positive and negative predictive value, accuracy, and R 2 . Results There were 808 patients who met inclusion criteria; 539 (66.7%) had open and 269 (33.3%) had laparoscopic PD. The CRS-PF was high risk in 134 patients, intermediate in 492, low in 135, and negligible in 47. Postoperative pancreatic fistula occurred in 191 (23.6%) patients (grade A, 3.8%; B, 14.2%; and C, 5.6%), and it increased with risk category (R 2  = 0.935 all, 0.898 open, and 0.968 laparoscopic). High and intermediate risk categories were combined and classified as "test positive," and negligible and low risk categories were combined and classified "test negative," resulting in a CRS-PF with a sensitivity of 95% and a negative predictive value of 96% for predicting POPF. Contrary to previous studies, grade A POPF increased with increasing CRS-PF and POPF did not correlate with estimated blood loss (R 2  = 0.04). Conclusions The CRS-PF was validated independently by predicting POPF for both laparoscopic and open PD. Predictive performance was at least as good for laparoscopic PD as for open PD. Lack of correlation with estimated blood loss suggests CRS-PF might be tailored for improved performance. The CRS-PF is a clinically useful tool for POPF risk stratification after PD and allows for targeted intra- and postoperative measures to address patients at increased risk.
  • References (23)
  • Citations (36)
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References23
Newest
#1Christopher R. Shubert (Mayo Clinic)H-Index: 9
#2Michael L. Kendrick (Mayo Clinic)H-Index: 45
Last. Elizabeth B. Habermann (Mayo Clinic)H-Index: 32
view all 5 authors...
Background Studies of pancreaticoduodenectomy (PD) frequently overlook diagnosis as a variable when evaluating postoperative outcomes or generically group patients according to whether they have ‘benign’ or ‘malignant’ disease. Large multicentre studies comparing postoperative outcomes in PD stratified by diagnosis are lacking. The present study was conducted to verify the hypothesis that postoperative morbidity and length of stay (LoS) following PD vary by diagnosis and that patients may be gro...
14 CitationsSource
Background Laparoscopic pancreaticoduodenectomy (LPD) is gaining momentum, but there is still uncertainty regarding its safety, reproducibility, and oncologic appropriateness. This review assesses the current status of LPD.
84 CitationsSource
#1Kris P. Croome (Mayo Clinic)H-Index: 13
#2Michael B. Farnell (Mayo Clinic)H-Index: 67
Last. Michael L. Kendrick (Mayo Clinic)H-Index: 45
view all 7 authors...
Background Major vascular resection when necessary for margin control during pancreaticoduodenectomy is relatively universal with perioperative and oncological outcomes that are similar to those of patients undergoing a PD without venous involvement. The present study compares total laparoscopic pancreaticoduodenectomy (TLPD) versus open pancreaticoduodenectomy (OPD) with major vascular resection.
70 CitationsSource
#1Benjamin C. Miller (UPenn: University of Pennsylvania)H-Index: 5
#2John D. Christein (UAB: University of Alabama at Birmingham)H-Index: 29
Last. Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 40
view all 7 authors...
Background The Fistula Risk Score (FRS), a ten-point scale that relies on weighted influence of four variables, has been shown to effectively predict clinically relevant postoperative pancreatic fistula (CR-POPF) development and its consequences after pancreatoduodenectomy (PD). The proposed FRS demonstrated excellent predictive capacity; however, external validation of this tool would confirm its universal applicability.
79 CitationsSource
#1Mark P. Callery (BIDMC: Beth Israel Deaconess Medical Center)H-Index: 48
#2Wande B. Pratt (WashU: Washington University in St. Louis)H-Index: 17
Last. Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 40
view all 5 authors...
Background Clinically relevant postoperative pancreatic fistulas (CR-POPF) are serious inherent risks of pancreatic resection. Preoperative CR-POPF risk assessment is currently inadequate and rarely disqualifies patients who need resection. The best evaluation of risk occurs intraoperatively, and should guide fistula prevention and response measures thereafter. We sought to develop a risk prediction tool for CR-POPF that features intraoperative assessment and reveals associated clinical and econ...
301 CitationsSource
Background Minimal access surgery techniques have evolved to include complex surgical procedures. Laparoscopic pancreaticoduodenectomy (LPD) is a complex operation that pancreas surgeons have been slow to adopt. This article reviews our experience with patients undergoing LPD and compares their outcomes with those of patients undergoing open pancreaticoduodenectomy (OPD). Study Design All patients undergoing OPD or LPD during a 6-year period (2005−2011) were included. Results from the 2 groups w...
227 CitationsSource
#1Toshiyuki Moriya (Mayo Clinic)H-Index: 4
#2Clancy J. Clark (Mayo Clinic)H-Index: 17
Last. Michael B. Farnell (Mayo Clinic)H-Index: 67
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Objective To evaluate the efficacy of transanastomotic pancreatic duct internal stenting in the reduction of postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy. Design Retrospective study. Setting Mayo Clinic. Patients Between January 1, 1999, and September 30, 2010, 553 patients underwent pancreaticoduodenectomy by a single surgeon. Main Outcome Measures Rates of POPF, morbidity, and mortality between stent and no-stent groups. Results The clinically relevant POPF (Internatio...
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#1David Yu Greenblatt (UW: University of Wisconsin-Madison)H-Index: 24
#2Kaitlyn J. Kelly (UW: University of Wisconsin-Madison)H-Index: 19
Last. Sharon M. Weber (UW: University of Wisconsin-Madison)H-Index: 37
view all 9 authors...
Background Pancreaticoduodenectomy (PD) has long been associated with high rates of morbidity and mortality. The objective of this study was to identify preoperative risk factors for serious complications and mortality after PD and to construct a prediction tool to facilitate risk stratification prior to surgery.
163 CitationsSource
#1Purvi Parikh (IUPUI: Indiana University – Purdue University Indianapolis)H-Index: 8
#2Mira Shiloach (ACS: American College of Surgeons)H-Index: 5
Last. Henry A. Pitt (IUPUI: Indiana University – Purdue University Indianapolis)H-Index: 37
view all 7 authors...
Background The morbidity of pancreatoduodenectomy remains high and the mortality may be significantly increased in high-risk patients. However, a method to predict post-operative adverse outcomes based on readily available clinical data has not been available. Therefore, the objective was to create a ‘Pancreatectomy Risk Calculator’ using the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database.
128 CitationsSource
#1Joshua S. Hill (UMMS: University of Massachusetts Medical School)H-Index: 17
#2Zheng Zhou (UMMS: University of Massachusetts Medical School)H-Index: 15
Last. Jennifer F. Tseng (UMMS: University of Massachusetts Medical School)H-Index: 37
view all 7 authors...
Background Pancreatectomy for cancer continues to have substantial perioperative risk, and the factors affecting mortality are ill defined. An integer-based risk score based on national data might help clarify the risk of in-hospital mortality in patients undergoing pancreatic resection.
65 CitationsSource
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#1Yoshito TomimaruH-Index: 25
Last. Keizo DonoH-Index: 40
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Purpose Pancreatic fistula (PF) is a common and serious complications after pancreaticoduodenectomy (PD). However, few studies have discussed the time required for PF healing in patients with this complication. This study investigates the PF healing time (PF-HT) and its association with findings of postoperative fistulography performed via the drainage tubes.
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#1Koichi Taniguchi (YCU: Yokohama City University)H-Index: 8
#2Ryusei Matsuyama (YCU: Yokohama City University)H-Index: 18
Last. Itaru Endo (YCU: Yokohama City University)H-Index: 38
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BACKGROUND/PURPOSE: Early drain removal (EDR) based on drain fluid amylase level (DFA) after pancreaticoduodenectomy excluded 15%-40% patients from EDR because of inappropriate DFA. METHODS: Of 198 pancreatoduodenectomy cases, we used the first 105 cases as an exploration cohort to construct the optimal criteria for EDR on postoperative day (POD)4 that were applied to the subsequent 93 cases used as the validation cohort. After that, we examined another 142 patients to further assess the efficac...
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#1Rajesh S. Shinde (ACTREC: Tata Memorial Hospital)H-Index: 1
#2Rajgopal Acharya (ACTREC: Tata Memorial Hospital)
Last. Shailesh V. Shrikhande (ACTREC: Tata Memorial Hospital)H-Index: 30
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Abstract Background Many postoperative pancreatic fistula (POPF) predictions models were developed and validated in western populations. Direct use of these models in the large Indian/Asian population, however, requires proper validation. Objective To validate the original, alternative and updated alternative fistula risk score (FRS) models. Methods A validation study was performed in consecutive patients undergoing pancreatoduodenectomy (PD) from January 2011 to March 2018. The area under the r...
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#1Timothy E. Newhook (University of Texas MD Anderson Cancer Center)H-Index: 3
#2Eduardo A. Vega (University of Texas MD Anderson Cancer Center)H-Index: 4
Last. Ching-Wei David Tzeng (University of Texas MD Anderson Cancer Center)H-Index: 19
view all 12 authors...
Abstract Background First postoperative day drain fluid amylase (DFA1) Methods Patients with DFA1/DFA3 values after pancreaticoduodenectomy or distal pancreatectomy were identified. Patients were risk stratified as “low-risk pancreaticoduodenectomy,” “high-risk pancreaticoduodenectomy,” or “distal pancreatectomy.” Receiver operator characteristic analyses yielded clinically relevant sensitivity thresholds for International Study Group on Pancreatic Surgery grade B/C postoperative pancreatic fist...
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#1Marco Angrisani (University of Milano-Bicocca)
#2Marta Sandini (University of Milano-Bicocca)H-Index: 9
Last. Luca Gianotti (University of Milano-Bicocca)H-Index: 35
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Abstract Background Anthropometric parameters have been associated with increased risk of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD). Nonetheless, conventional metrics to predict POPF do not include the assessment of body composition. We aimed to validate the most used Fistula Risk Score (FRS), and to assess whether the appraisal of adipose compartment at bioimpedance vector analysis (BIVA) improves the accuracy of FRS in CR-POPF prediction....
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AbstractBackground: This retrospective comparative case series study aims to analyze the pancreatic fistula rates of internal and external stenting of the pancreatojejunostomy (PJ) anastomosis in p...
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#1Mengyi Lao (ZJU: Zhejiang University)H-Index: 1
#2Xiaozhen Zhang (ZJU: Zhejiang University)H-Index: 2
Last. Tingbo Liang (ZJU: Zhejiang University)H-Index: 26
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Abstract Background The utility of the proposed alternative fistula risk score (a-FRS) for predicting risk of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD) has not been validated widely. Methods This retrospective analysis included data of patients undergoing open and laparoscopic PD during March 2012–May 2018 in our institution. The predictive abilities of a-FRS and original-FRS were compared. Risk factors for CR-POPF were also evaluated by mu...
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#1Julie PerinelH-Index: 7
#2Antoine DuclosH-Index: 17
Last. Mustapha AdhamH-Index: 23
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BACKGROUND: Implementation of enhanced recovery after surgery (ERAS) program after pancreatic surgery was associated with decreased length of stay (LOS). However, there were only retrospective uncontrolled before-after study, and care protocols were heterogeneous. We aimed to evaluate the impact of ERAS program on postoperative outcomes after pancreatectomy through a prospective controlled study. METHODS: A before/after study with a contemporary control group was undertaken in patients undergoin...
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#1Thomas Hank (Harvard University)H-Index: 7
#2Marta Sandini (Harvard University)H-Index: 4
Last. Carlos Fernandez-del Castillo (Harvard University)H-Index: 82
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Importance In the past decade, the use of neoadjuvant therapy (NAT) has increased for patients with borderline and locally advanced pancreatic ductal adenocarcinoma (PDAC). Data on pancreatic fistula and related overall survival (OS) in this setting are limited. Objective To compare postoperative complications in patients undergoing either upfront resection or pancreatectomy following NAT, focusing on clinically relevant postoperative pancreatic fistula (CR-POPF) and potential associations with ...
5 CitationsSource
#1Y. Ryu (SMC: Samsung Medical Center)
#2Sang Hyun Shin (SMC: Samsung Medical Center)
Last. In Woong Han (SMC: Samsung Medical Center)H-Index: 2
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BACKGROUND: In 2013, the fistula risk score (FRS) was developed to assess the risk of clinically relevant postoperative pancreatic fistula (CR-POPF). In 2017, the alternative FRS (a-FRS) was proposed. The purpose of this study was to validate the original FRS (o-FRS) and a-FRS for CR-POPF in pancreaticoduodenectomy (PD). METHODS: From January 2007 to December 2016, 1,771 patients underwent PD for periampullary cancers. POPF was defined and classified according to the 2016 International Study Gro...
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