Journal of Gastrointestinal Surgery

, Volume 18, Issue 1, pp 172–180 | Cite as

A Multi-Institutional External Validation of the Fistula Risk Score for Pancreatoduodenectomy

  • Benjamin C. Miller
  • John D. Christein
  • Stephen W. Behrman
  • Jeffrey A. Drebin
  • Wande B. Pratt
  • Mark P. Callery
  • Charles M. VollmerJr.Email author
2013 SSAT Plenary Presentation



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.


From 2001 to 2012, 594 PDs with pancreatojejunostomy reconstructions were performed at three institutions. POPFs were graded by International Study Group on Pancreatic Fistula standards as grades A, B, or C. The FRS was calculated for each patient, and clinical outcomes were evaluated across four discrete risk zones as described in the original work. Receiver operator curve analysis was performed to judge model validity.


One hundred forty-two patients developed any sort of POPF, of which 68 were CR-POPF (11.4 % overall; 8.9 % grade B, 2.5 % grade C). Increasing FRS scores (0–10) correlated well with CR-POPF development (p < 0.001) with a C-statistic of 0.716. When segregated by discrete FRS-risk groups, CR-POPFs occurred in low-, moderate-, and high-risk patients, 6.6, 12.9, and 28.6 % of the time, respectively (p < 0.001). Clinical outcomes including complications, length of stay, and readmission rates also increased across risk groups.


This multi-institutional experience confirms the Fistula Risk Score as a valid tool for predicting the development of CR-POPF after PD. Patients devoid of any risk factors did not develop a CR-POPF, and the rate of CR-POPF approximately doubles with each subsequent risk zone. The FRS is validated as a strongly predictive tool, with widespread applicability, which can be readily incorporated into common clinical practice and research analysis.


Fistula Risk Score Pancreaticoduodenectomy Pancreatic fistula Risk prediction POPF 



  1. 1.
    van Berge Henegouwen MI, De Wit LT, Van Gulik TM, Obertop H, Gouma DJ. Incidence, risk factors, and treatment of pancreatic leakage after pancreaticoduodenectomy: drainage versus resection of the pancreatic remnant. J Am Coll Surg. 1997; 185:18–24.PubMedCrossRefGoogle Scholar
  2. 2.
    Gouma DJ, van Geenen RC, van Gulik TM, de Haan RJ, de Wit LT, Busch OR, Obertop H. Rates of complications and death after pancreaticoduodenectomy: risk factors and the impact of hospital volume. Ann Surg. 2000; 232:786–795.PubMedCrossRefGoogle Scholar
  3. 3.
    Bassi C, Butturini G, Molinari E, Mascetta G, Salvia R, Falconi M, Gumbs A, Pederzoli P. Pancreatic fistula rate after pancreatic resection: the importance of definitions. Dig Surg. 2004; 21:54–59.PubMedCrossRefGoogle Scholar
  4. 4.
    Hackert T, Werner J, Buchler M. Postoperative pancreatic fistula. Surgeon. 2011; 9(4):211–17PubMedCrossRefGoogle Scholar
  5. 5.
    Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, Neoptolemos J, Sarr M, Traverso W, Buchler M. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery. 2005; 138:8–13.PubMedCrossRefGoogle Scholar
  6. 6.
    Pratt WB, Callery MP, Vollmer CM. Risk prediction for development of pancreatic fistula using the ISGPF classification scheme. World J Surg 2008; 32:419–428.PubMedCrossRefGoogle Scholar
  7. 7.
    Callery MP, Pratt WB, Vollmer CM. Prevention and management of pancreatic fistula. J Gastrointest Surg 2009; 13:163–173.PubMedCrossRefGoogle Scholar
  8. 8.
    Ansorge C, Strommer L, Andren-Sandberg A, Lundell L, Herrington M K, Segersvard R. Structured intraoperative assessment of pancreatic gland characteristics in predicting complications after pancreaticoduodenectomy. British Journal of Surgery. 2012; 99:1076–1082.PubMedCrossRefGoogle Scholar
  9. 9.
    Wellner U, Kayser G, Lapshyn H, Sick O, Makewiec F, Hoppner J, Hopt U, Keck T. A simple scoring system based on clinical factors related to pancreatic texture predicts postoperative pancreatic fistula preoperatively. HPB. 2010; 12(10):696–702PubMedCentralPubMedCrossRefGoogle Scholar
  10. 10.
    Muscari F, Suc B, Kirzin S, Hay J, Fourtanier G, Fingerhut A, Sastre B, Chipponi J, Fagniez P, Radovanovic A, French associations for surgical research. Risk factors for mortality and intraabdominal complications after pancreatoduodenectomy: multivariate analysis in 300 patients. Surgery. 2006; 139(5):591–9PubMedCrossRefGoogle Scholar
  11. 11.
    Hashimoto Y, Sclabas G, Takahashi N, Kirihara Y, Smyrk T, Huebner M, Farnell M. Dual-phase computed tomography for assessment of pancreatic fibrosis and anastomotic failure risk following pancreatoduodenectomy. JOGS. 2011; 15(12):2193–204.Google Scholar
  12. 12.
    Callery MP, Pratt WB, Kent TS, Chaikof EL, Vollmer CM. A prospectively validated risk score accurately predicts pancreatic fistula after pancreatoduodenectomy. J Am Coll Surg. 2013; 216:1–14.PubMedCrossRefGoogle Scholar
  13. 13.
    Strasberg SM, Hall BL. Postoperative morbidity index: a quantitative measure of severity of postoperative complications. J Am Coll Surg. 2011; 213:616–626.PubMedCrossRefGoogle Scholar
  14. 14.
    Miller B, Christein D, Behrman S, Callery M, Drebin J, Kent T, Pratt W, Lewis R, Vollmer C. Assessing the impact of fistula after pancreaticoduodenectomy using the postoperative morbidity index. HPB. 2013. doi: 10.1111/hpb.12131
  15. 15.
    The Pancreas Club. ISGPS calculator—The pancreas club. 2012 Available from:
  16. 16.
    Hashimoto Y, Traverso L. Incidence of pancreatic anastomotic failure and delayed gastric emptying after pancreatoduodenectomy in 507 consecutive patients: use of a web-based calculator to improve homogeneity of definition. Surgery. 2010; 147(4):503–15PubMedCrossRefGoogle Scholar
  17. 17.
    Ferrone C, Kattan M, Tomlinson J, Thayer S, Brennan M, Warshaw A. Validation of a postresection pancreatic adenocarcinoma nomogram for disease-specific survival. J Clin Oncol. 2005; 23:7529–7535PubMedCrossRefGoogle Scholar
  18. 18.
    Brennan M, Kattan M, Klimstra D, Conlon K. Prognostic nomogram for patients undergoing resection for adenocarcinoma of the pancreas. Ann Surg. 2004; 240(2):293–8PubMedCrossRefGoogle Scholar
  19. 19.
    Rockhill B, Spiegelman D, Byrne C, Hunter D, Colditz G. Validation of the Gail et al. model of breast cancer risk prediction and implications for chemoprevention. J Natl Cancer Inst. 2001; 93:358–366PubMedCrossRefGoogle Scholar
  20. 20.
    Sachs T, Pratt W, Kent T, Callery M, Vollmer C. The pancreaticojejunal stent: Friend or foe. Surgery. 2013; 153(5):651–62Google Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2013

Authors and Affiliations

  • Benjamin C. Miller
    • 1
  • John D. Christein
    • 2
  • Stephen W. Behrman
    • 3
  • Jeffrey A. Drebin
    • 1
  • Wande B. Pratt
    • 4
  • Mark P. Callery
    • 4
  • Charles M. VollmerJr.
    • 1
    Email author
  1. 1.Department of Surgery, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaUSA
  2. 2.Department of SurgeryUniversity of Alabama, Birmingham Medical CenterBirminghamUSA
  3. 3.Department of SurgeryUniversity of Tennessee Health Sciences CenterMemphisUSA
  4. 4.Department of SurgeryBeth Israel Deaconess Medical Center, Harvard Medical SchoolBostonUSA

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