Alternative Fistula Risk Score for Pancreatoduodenectomy (a-FRS) Design and International External Validation

Timothy H. Mungroop*, L. Bengt van Rijssen, David van Klaveren, F. Jasmijn Smits, Victor van Woerden, Ralph J. Linnemann, Matteo de Pastena, Sjors Klompmaker, Giovanni Marchegiani, Brett L. Ecker, Susan van Dieren, Bert Bonsing, Olivier R. Busch, Ronald M. van Dam, Joris Erdmann, Casper H. van Eijck, Michael E. Gerhards, Harry van Goor, Erwin van der Harst, Ignace H. de HinghKoert P. de Jong, Geert Kazemier, Misha Luyer, Awad Shamali, Salvatore Barbaro, Thomas Armstrong, Arjun Takhar, Zaed Hamady, Joost Klaase, Daan J. Lips, I. Quintus Molenaar, Vincent B. Nieuwenhuijs, Coen Rupert, Hjalmar C. van Santvoort, Joris J. Scheepers, George P. van der Schelling, Claudio Bassi, Charles M. Vollmer, Ewout W. Steyerberg, Mohammed Abu Hilal, Bas Groot Koerkamp, Marc G. Besselink*, Dutch Pancreatic Canc Grp

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

147 Citations (Web of Science)


Objective: The aim of this study was to develop an alternative fistula risk score (a-FRS) for postoperative pancreatic fistula (POPF) after pancreatoduodenectomy, without blood loss as a predictor.

Background: Blood loss, one of the predictors of the original-FRS, was not a significant factor during 2 recent external validations.

Methods: The a-FRS was developed in 2 databases: the Dutch Pancreatic Cancer Audit (18 centers) and the University Hospital Southampton NHS. Primary outcome was grade B/C POPF according to the 2005 International Study Group on Pancreatic Surgery (ISGPS) definition. The score was externally validated in 2 independent databases (University Hospital of Verona and University Hospital of Pennsylvania), using both 2005 and 2016 ISGPS definitions. The a-FRS was also compared with the original-FRS.

Results: For model design, 1924 patients were included of whom 12% developed POPE Three predictors were strongly associated with POPF: soft pancreatic texture [odds ratio (OR) 2.58, 95% confidence interval (95% CI) 1.80-3.69], small pancreatic duct diameter (per mm increase, OR: 0.68, 95% CI: 0.61-0.76), and high body mass index (BMI) (per kg/m(2) increase, OR: 1.07, 95% CI: 1.04-1.11). Discrimination was adequate with an area under curve (AUC) of 0.75 (95% CI: 0.71-0.78) after internal validation, and 0.78 (0.74-0.82) after external validation. The predictive capacity of a-FRS was comparable with the original-FRS, both for the 2005 definition (AUC 0.78 vs 0.75, P = 0.03), and 2016 definition (AUC 0.72 vs 0.70, P = 0.05).

Conclusion: The a-FRS predicts POPF after pancreatoduodenectomy based on 3 easily available variables (pancreatic texture, duct diameter, BMI) without blood loss and pathology, and was successfully validated for both the 2005 and 2016 POPF definition. The online calculator is available at .

Original languageEnglish
Pages (from-to)937-943
Number of pages7
JournalAnnals of Surgery
Issue number5
Publication statusPublished - May 2019


  • complication
  • pancreas
  • pancreatic fistula
  • prediction model

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