title: Clinical Risk Score to Predict Pancreatic Fistula after Pancreatoduodenectomy: Independent External Validation for Open and Laparoscopic Approaches.
abstract: BACKGROUND
  A clinical risk score for pancreatic fistula (CRS-PF) was recently reported to predict postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD). An independent external validation has not been performed. Our hypothesis was that CRS-PF predicts POPF after both laparoscopic and open PD.
  
  
  METHODS
  The CRS-PF was calculated from a retrospective review of patients undergoing PD from January 2007 to February 2014. Postoperative pancreatic fistula was graded using International Study Group of Pancreatic Fistula criteria. Grade B and C leaks were defined as clinically significant. Performance was measured based on sensitivity, specificity, positive and negative predictive value, accuracy, and R(2).
  
  
  RESULTS
  There were 808 patients who met inclusion criteria; 539 (66.7%) had open and 269 (33.3%) had laparoscopic PD. The CRS-PF was high risk in 134 patients, intermediate in 492, low in 135, and negligible in 47. Postoperative pancreatic fistula occurred in 191 (23.6%) patients (grade A, 3.8%; B, 14.2%; and C, 5.6%), and it increased with risk category (R(2) = 0.935 all, 0.898 open, and 0.968 laparoscopic). High and intermediate risk categories were combined and classified as "test positive," and negligible and low risk categories were combined and classified "test negative," resulting in a CRS-PF with a sensitivity of 95% and a negative predictive value of 96% for predicting POPF. Contrary to previous studies, grade A POPF increased with increasing CRS-PF and POPF did not correlate with estimated blood loss (R(2) = 0.04).
  
  
  CONCLUSIONS
  The CRS-PF was validated independently by predicting POPF for both laparoscopic and open PD. Predictive performance was at least as good for laparoscopic PD as for open PD. Lack of correlation with estimated blood loss suggests CRS-PF might be tailored for improved performance. The CRS-PF is a clinically useful tool for POPF risk stratification after PD and allows for targeted intra- and postoperative measures to address patients at increased risk.
authors: Division of Subspecialty General Surgery, Department of Surgery, Section of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN; Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Surgical Outcomes Program, Mayo Clinic, Rochester, MN.
authors: Christopher R
authors: CR
authors: Shubert
authors: Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Surgical Outcomes Program, Mayo Clinic, Rochester, MN.
authors: Amy E
authors: AE
authors: Wagie
authors: Division of Subspecialty General Surgery, Department of Surgery, Section of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN.
authors: Michael B
authors: MB
authors: Farnell
authors: Division of Subspecialty General Surgery, Department of Surgery, Section of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN.
authors: David M
authors: DM
authors: Nagorney
authors: Division of Subspecialty General Surgery, Department of Surgery, Section of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN.
authors: Florencia G
authors: FG
authors: Que
authors: Division of Subspecialty General Surgery, Department of Surgery, Section of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN.
authors: K Marie
authors: KM
authors: Reid Lombardo
authors: Division of Subspecialty General Surgery, Department of Surgery, Section of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN.
authors: Mark J
authors: MJ
authors: Truty
authors: Division of Subspecialty General Surgery, Department of Surgery, Section of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN.
authors: Rory L
authors: RL
authors: Smoot
authors: Division of Subspecialty General Surgery, Department of Surgery, Section of Hepatobiliary and Pancreas Surgery, Mayo Clinic, Rochester, MN. Electronic address: Kendrick.Michael@mayo.edu.
authors: Michael L
authors: ML
authors: Kendrick
mesh_terms: D000368:Aged; D005260:Female; D006801:Humans; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D010185:Pancreatic Fistula / Q000209:etiology*; D016577:Pancreaticoduodenectomy / Q000009:adverse effects*; D012189:Retrospective Studies; D018570:Risk Assessment; D012680:Sensitivity and Specificity