A Prospectively Validated Clinical Risk Score Accurately Predicts Pancreatic Fistula after Pancreatoduodenectomy : Journal of the American College of Surgeons

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Original scientific article

A Prospectively Validated Clinical Risk Score Accurately Predicts Pancreatic Fistula after Pancreatoduodenectomy

Callery, Mark P. MD, FACSa; Pratt, Wande B. MD, MPHb; Kent, Tara S. MD, FACSa; Chaikof, Elliot L. MD, PhD, FACSa; Vollmer, Charles M. Jr. MD, FACSc,*

Author Information

aDepartment of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA

bDepartment of Surgery, Barnes Jewish Hospital, Washington University School of Medicine, St Louis, MO

cDepartment of Surgery, Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine, Philadelphia, PA

*Correspondence address: Charles M Vollmer Jr, MD, FACS, Department of Surgery, University of Pennsylvania School of Medicine, 3400 Spruce St, 4th Floor, Silverstein Pavilion, Philadelphia, PA 19104.

email: [email protected]

Received July 16, 2012; Revised and Accepted September 5, 2012.

CME questions for this article available athttp://jacscme.facs.org

Disclosure Information: Authors have nothing to disclose. Timothy J Eberlein, Editor-in-Chief, has nothing to disclose.

Presented at the American College of Surgeons 97th Annual Clinical Congress, San Francisco, CA, October 2011.

Journal of the American College of Surgeons 216(1):p 1-14, January 2013. | DOI: 10.1016/j.jamcollsurg.2012.09.002

Abstract

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 economic significance.

STUDY DESIGN: 

Based on International Study Group of Pancreatic Fistula classification, recognized risk factors for CR-POPF (small duct, soft pancreas, high-risk pathology, excessive blood loss) were evaluated during pancreaticoduodenectomy. An optimal risk score range model, selected from 3 different constructs, was first derived (n = 233) and then validated prospectively (n = 212). Clinical and economic outcomes were evaluated across 4 ranges of scores (negligible risk, 0 points; low risk, 1 to 2; intermediate risk, 3 to 6; high risk, 7 to 10).

RESULTS: 

Clinically relevant postoperative pancreatic fistulas occurred in 13% of patients. The incidence was greatest with excessive blood loss. Duct size <5 mm was associated with increased fistula rates that rose with even smaller ducts. These factors, together with soft pancreatic parenchyma and certain disease pathologies, afforded a highly predictive 10-point Fistula Risk Score. Risk scores strongly correlated with fistula development (p < 0.001). Notably, patients with scores of 0 points never developed a CR-POPF, while fistulas occurred in all patients with scores of 9 or 10. Other clinical and economic outcomes segregated by risk profile across the 4 risk strata.

CONCLUSIONS: 

A simple 10-point Fistula Risk Score derived during pancreaticoduodenectomy accurately predicts subsequent CR-POPF. It can be readily learned and broadly deployed. This prediction tool can help surgeons anticipate, identify, and manage this ominous complication from the outset.

© 2013 by Lippincott Williams & Wilkins, Inc.

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