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Incorporation of Procedure-specific Risk Into the ACS-NSQIP Surgical Risk Calculator Improves the Prediction of Morbidity and Mortality After Pancreatoduodenectomy

McMillan, Matthew T. BA*; Allegrini, Valentina MD; Asbun, Horacio J. MD; Ball, Chad G. MD, MSc§; Bassi, Claudio MD; Beane, Joal D. MD; Behrman, Stephen W. MD||; Berger, Adam C. MD**; Bloomston, Mark MD††; Callery, Mark P. MD‡‡; Christein, John D. MD§§; Dickson, Euan MD¶¶; Dixon, Elijah MD, MSc§; Drebin, Jeffrey A. MD, PhD*; Fernandez-Del Castillo, Carlos MD||||; Fisher, William E. MD***; Fong, Zhi Ven MD||||; Haverick, Ericka BSN††; Hollis, Robert H. MD§§; House, Michael G. MD; Hughes, Steven J. MD†††; Jamieson, Nigel B. MD¶¶; Kent, Tara S. MD‡‡; Kowalsky, Stacy J. MD‡‡‡; Kunstman, John W. MD§§§; Malleo, Giuseppe MD; McElhany, Amy L. MPH***; Salem, Ronald R. MD§§§; Soares, Kevin C. MD¶¶¶; Sprys, Michael H. MS*; Valero, Vicente III MD¶¶¶; Watkins, Ammara A. MD‡‡; Wolfgang, Christopher L. MD, PhD¶¶¶; Zureikat, Amer H. MD‡‡‡; Vollmer, Charles M. Jr. MD*

doi: 10.1097/SLA.0000000000001796
Original Articles

Objective: This multicenter study sought to evaluate the accuracy of the American College of Surgeons National Surgical Quality Improvement Program's (ACS-NSQIP) surgical risk calculator for predicting outcomes after pancreatoduodenectomy (PD) and to determine whether incorporating other factors improves its predictive capacity.

Background: The ACS-NSQIP surgical risk calculator has been proposed as a decision-support tool to predict complication risk after various operations. Although it considers 21 preoperative factors, it does not include procedure-specific variables, which have demonstrated a strong predictive capacity for the most common and morbid complication after PD – clinically relevant pancreatic fistula (CR-POPF). The validated Fistula Risk Score (FRS) intraoperatively predicts the occurrence of CR-POPF and serious complications after PD.

Methods: This study of 1480 PDs involved 47 surgeons at 17 high-volume institutions. Patient complication risk was calculated using both the universal calculator and a procedure-specific model that incorporated the FRS and surgeon/institutional factors. The performance of each model was compared using the c-statistic and Brier score.

Results: The FRS was significantly associated with 30-day mortality, 90-day mortality, serious complications, and reoperation (all P < 0.0001). The procedure-specific model outperformed the universal calculator for 30-day mortality (c-statistic: 0.79 vs 0.68; Brier score: 0.020 vs 0.021), 90-day mortality, serious complications, and reoperation. Neither surgeon experience nor institutional volume significantly predicted mortality; however, surgeons with a career PD volume >450 were less likely to have serious complications (P < 0.001) or perform reoperations (P < 0.001).

Conclusions: Procedure-specific complication risk influences outcomes after pancreatoduodenectomy; therefore, risk adjustment for performance assessment and comparative research should consider these preoperative and intraoperative factors along with conventional ACS-NSQIP preoperative variables.

*Departments of Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA

Departments of Surgery, University of Verona, Verona, Italy

Departments of Surgery, Mayo Clinic, Jacksonville, FL

§Departments of Surgery, University of Calgary, Calgary, Alberta

Departments of Surgery, Indiana University School of Medicine, Indianapolis, IN

||Departments of Surgery, University of Tennessee Health Science Center, Memphis, TN

**Departments of Surgery, Jefferson Medical College, Philadelphia, PA

††Departments of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH

‡‡Departments of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA

§§Departments of Surgery, University of Alabama School of Medicine, Birmingham, AL

¶¶Departments of Surgery, University of Glasgow, Glasgow, Scotland

||||Departments of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA

***Departments of Surgery, Baylor College of Medicine, Houston, TX

†††Departments of Surgery, University of Florida College of Medicine, Gainesville, FL

‡‡‡Departments of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA

§§§Departments of Surgery, Yale School of Medicine, New Haven, CT

¶¶¶Departments of Surgery, Johns Hopkins School of Medicine, Baltimore, MD.

Reprints: Charles M. Vollmer, Jr., MD, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104. E-mail: Charles.Vollmer@uphs.upenn.edu.

Disclosure: The authors declare no conflicts of interest.

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