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

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.