Using the NSQIP Pancreatic Demonstration Project to Derive a Modified Fistula Risk Score for Preoperative Risk Stratification in Patients Undergoing Pancreaticoduodenectomy

In Brief BACKGROUND: The Fistula Risk Score (FRS) is a clinical tool developed from single-institutional data using primarily intraoperative factors to characterize the risk of clinically relevant pancreatic fistula (CR-POPF) after pancreaticoduodenectomy. We developed a modified FRS based on objective, nationally accrued data that is more readily determined before resection. STUDY DESIGN: The 2012 NSQIP Pancreatic Demonstration Project (PDP) was used to identify 1,731 pancreaticoduodenectomy resections over 14 months (2011 to 2012). A randomly generated 70% cohort was used for model development, and the remaining 30% for internal validation. Univariate analysis was used to identify predictors of CR-POPF. Variables with a value of p < 0.1 were included in multivariable modeling. RESULTS: Five significant predictors of CR-POPF were identified and assigned points based on odds ratios: sex, BMI, preoperative total bilirubin, pancreatic ductal diameter, and gland texture. The 10-point model was further applied to the 2014 PDP for external validation. In the testing group, risk scores of 0 to 2 (negligible risk), 3 to 6 (low risk), 7 to 8 (intermediate risk), and 9 to 10 (high risk) were associated with CR-POPF rates of 0%, 6.7%, 16.4%, and 33.7%, respectively. Similar values were seen using the internal validation cohort: 0%, 6.3%, 13.5%, and 31.0%, respectively. The external validation values were 2.9%, 10.2%, 16.4%, and 25.8%, respectively. CONCLUSIONS: This modified FRS allows for estimation of CR-POPF risk using preoperative and easily determined intraoperative factors, and will allow comparison of performance data for individual surgeons to national norms, improved perioperative counseling, and potential for scrutinizing and/or implementing interventions designed to decrease CR-POPF rates. We derived a modified fistula risk score to predict clinically relevant postoperative pancreatic fistula, incorporating 5 risk factors: sex, BMI, preoperative total bilirubin, pancreatic duct diameter, and pancreatic gland texture. This tool has the potential to improve preoperative risk stratification and allow institutional comparisons with national norms.