Alternative fistula risk score is a better predictor of ideal outcome in patients undergoing minimally invasive pancreaticoduodenectomy

Abstract

Background: The benefit of minimally-invasive (MIPD) versus open pancreaticoduodenectomy (OPD) to patients is controversial. The major driver of morbidity and mortality after pancreaticoduodenectomy is postoperative pancreatic-fistula (POPF). The alternative-fistula risk score (aFRS) is a validated prognostic tool that predicts patients' risk of POPF using three variables (pancreatic duct size, gland texture, and patient BMI). We hypothesized that patients who are not at high risk for POPF benefit most from MIPD. Methods: Patients undergoing pancreaticoduodenectomy were prospectively followed for 40 months. Perioperative and pathologic covariates and outcomes were compared. Patients were categorized as either aFRS-high risk (POPF-risk >20%) or aFRS-low/intermediate-risk (POPF-risk ≤20%). The ideal-outcome (IO) was defined as shown in Figure-1. Multivariable logistic regression was used to test for independent-associations with IO. Results: Out of 312 patients, 212 (83.7%) underwent OPD and 51 (16.4%) underwent MIPD. MIPD patients had significantly longer overall operative time (462.8 minvs.378.5 min,p< 0.001), reduced intraoperative blood loss (280.5 mlvs.436.0 ml,p=0.001), and a decreased rate of 90-day readmission (15.7%vs.30.7%,p=0.030) . MIPD patients were significantly more likely to be aFRS-high risk (56.9%vs.40.2%,p=0.028). IO was significantly more frequent in aFRS-low/intermediate-risk patients undergoing MIPD compared to aFRS-low/intermediate-risk patients undergoing OPD, aFRS-high risk patients undergoing either MIPD or OPD (40.9%vs15.4%v6.9% vs14.3%,p=0.007). In multivariate analysis, MIPD in aFRS-low/intermediate-risk patients was independently-associated with an increased likelihood of IO (OR= 4.09, p=0.012). Conclusions: Patients who are not at high-risk for POPF are most likely to benefit from MIPD. The aFRS could be a useful tool to aid the surgeon experience and expertise in selecting patients for MIPD.