Risk-adjusted Outcomes of Clinically Relevant Pancreatic Fistula Following Pancreatoduodenectomy: A Model for Performance Evaluation

Matthew T. McMillan, Sameer Soi, Horacio J. Asbun, Chad G. Ball, Claudio Bassi, Joal D. Beane, Stephen W. Behrman, Adam C. Berger, Mark Bloomston, Mark P. Callery, John D. Christein, Elijah Dixon, Jeffrey A. Drebin, Carlos Fernandez Del Castillo, William E. Fisher, Zhi Ven Fong, Michael G. House, Steven J. Hughes, Tara S. Kent, John W. KunstmanGiuseppe Malleo, Benjamin C. Miller, Ronald R. Salem, Kevin Soares, Vicente Valero, Christopher L. Wolfgang, Charles M. Vollmer

Research output: Contribution to journalArticlepeer-review

89 Scopus citations


Objective: To evaluate surgical performance in pancreatoduodenectomy using clinically relevant postoperative pancreatic fistula (CR-POPF) occurrence as a quality indicator. Background: Accurate assessment of surgeon and institutional performance requires (1) standardized definitions for the outcome of interest and (2) a comprehensive risk-adjustment process to control for differences in patient risk. Methods: This multinational, retrospective study of 4301 pancreatoduodenectomies involved 55 surgeons at 15 institutions. Risk for CR-POPF was assessed using the previously validated Fistula Risk Score, and pancreatic fistulas were stratified by International Study Group criteria. CR-POPF variability was evaluated and hierarchical regression analysis assessed individual surgeon and institutional performance. Results: There was considerable variability in both CR-POPF risk and occurrence. Factors increasing the risk for CR-POPF development included increasing Fistula Risk Score (odds ratio 1.49 per point, P < 0.00001) and octreotide (odds ratio 3.30, P < 0.00001). When adjusting for risk, performance outliers were identified at the surgeon and institutional levels. Of the top 10 surgeons (≥15 cases) for nonrisk-adjusted performance, only 6 remained in this high-performing category following risk adjustment. Conclusions: This analysis of pancreatic fistulas following pancreatoduodenectomy demonstrates considerable variability in both the risk and occurrence of CR-POPF among surgeons and institutions. Disparities in patient risk between providers reinforce the need for comprehensive, risk-adjusted modeling when assessing performance based on procedure-specific complications. Furthermore, beyond inherent patient risk factors, surgical decision-making influences fistula outcomes.

Original languageEnglish (US)
Pages (from-to)344-352
Number of pages9
JournalAnnals of surgery
Issue number2
StatePublished - Aug 1 2016


  • Fistula Risk Score
  • pancreatic fistula
  • pancreatoduodenectomy
  • performance assessment
  • risk adjustment

ASJC Scopus subject areas

  • Surgery


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