?

External validation of PREPARE score in Turkish patients who underwent pancreatic surgery

To the Editor:

We have read with interest the article by Uzunoglu et al[1]entitled “Preoperative pancreatic resection (PREPARE) score: a prospective multicenter-based morbidity risk score” for prediction of postoperative morbidity and mortality related to pancreatic resection. Pancreatic resections are generally considered as difficult operations due to the high risk of perioperative morbidity.[2]The existing preoperative risk grading systems do not provide an optimal risk stratification. We have validated the PREPARE score in Turkish patients in the past years.

Between 2010 and 2015, 122 patients who underwent pancreatic resection due to disease of pancreatic origin or not and had no positive resection margins on final pathology report were included for the evaluation. Postoperative complications were determined according to the Clavien-Dindo classification,[3]and complications graded as III to V were defined as major. The PREPARE score was calculated using eight certain parameters (Table 1). The patients were divided into the low-risk (<6 points), intermediate-risk (6-9 points), and high-risk (>9 points) groups.

Model discrimination was measured by the area under the receiver-operating characteristic (ROC) curve (AUC). Calibration was assessed using the Hosmer-Lemeshow goodness-of-fit test and the corresponding calibration curves. Statistical evaluation has been performed by using the STATA 8.0 statistical package (StataCorp, LP).

The main characteristics and the PREPARE parameters of the patients are presented in Table 1. There was no major complication in the low-risk group; however, 68.6% and 31.4% of the major complications occurred in the high-risk group and intermediate-risk group (Table 2). The ROC curve showing the discriminative power of the PREPARE score was found to be 0.541, while the calibration was 3.352 in Hosmer-Lemeshow Chi2test with a P value of 0.764. Within the validation cohort, approximately 70% of all patients were classified as either low-risk or high-risk groups with an accuracy rate of 70%.

Table 1. The main characteristics and the PREPARE score parameters of the patients

Table 2. Frequency of complications according to the Clavien-Dindo classification in the risk groups of the validation cohort (n, %)___

The preoperative risk scoring systems can be classified into two groups. The first group includes grading systems such as the ASA score, acute physiology and chronic health evaluation (APACHE-II) score, and physiological and operative severity scoring system for enumeration of morbidity and mortality (POSSUM) score, indicating an overall operative risk in various specialities. The second group is specialized to pancreatic surgery, and includes scoring systems such as readmission after pancreatectomy (RAP) score, PREPARE score, and Braga score.[1, 4, 5]Simple and easily accessible variables and taking into account the patients’ cardiovascular and nutritional status seem to be the most important advantages of the PREPARE score. However, several anatomical features such as pancreatic texture and duct diameterare of great importance for the surgical outcomes of pancreatic resections.[6]Although these parameters can only be assessed intraoperatively and thus cannot provide any preoperative decision making, we suggest that a risk stratification without these parameters cannot completely reflect the accurate prediction of postoperative complications. The experience of the center and type of operative technique also have significant impact on outcomes. The authors reproted that the PREPARE score reached an accuracy of 75% for correctly predicting occurrence or nonoccurrence of major surgical complications in 80% of all analyzed patients within the validation cohort. We also obtained an accuracy rate of 70%, and for our opinion, these accuracy rates are not enough to show the success and reliability of this scoring system.

Despite these limitations, the PREPARE score seems to be the most simple and useful scoring system among all grading methods, and can be easily used in routine practice for risk stratification for patients undergoing pancreatic resections.

Hüseyin Celik, Murat Ozgur Kilic, Ahmet Erdogan,

Cengiz Ceylan and Mesut Tez

Clinic of General Surgery,

Numune Training and Research Hospital,

Ankara, Turkey

Email: murat05ozgur@hotmail.com

References

1 Uzunoglu FG, Reeh M, Vettorazzi E, Ruschke T, Hannah P, Nentwich MF, et al. Preoperative pancreatic resection (PREPARE) score: a prospective multicenter-based morbidity risk score. Ann Surg 2014;260:857-864.

2 Büchler MW, Wagner M, Schmied BM, Uhl W, Friess H, Z’ graggen K. Changes in morbidity after pancreatic resection: toward the end of completion pancreatectomy. Arch Surg 2003;138:1310-1315.

3 Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, et al. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 2009; 250:187-196.

4 Valero V 3rd, Grimm JC, Kilic A, Lewis RL, Tosoian JJ, He J, et al. A novel risk scoring system reliably predicts readmission after pancreatectomy. J Am Coll Surg 2015;220:701-713.

5 Braga M, Capretti G, Pecorelli N, Balzano G, Doglioni C, Ariotti R, et al. A prognostic score to predict major complications after pancreaticoduodenectomy. Ann Surg 2011;254:702-708.

6 Casadei R, Ricci C, Taffurelli G, D’Ambra M, Pacilio CA, Ingaldi C, et al. Are there preoperative factors related to a “soft pancreas” and are they predictive of pancreatic fistulas after pancreatic resection? Surg Today 2015;45:708-714.

Published online January 7, 2016.

The Author Reply:

We read with interest the article “External validation of PREPARE score in Turkish patients who underwent pancreatic surgery” that analyzes the PREPARE score published in Annals of Surgery in 2014.[1]One hundred and twenty-two Turkish patients who underwent pancreatic surgery were analyzed postoperatively by the PREPARE score. An accuracy of 70% of the score was found. The authors concluded that despite limitations, the PREPARE score seems to be the most simple and useful scoring system among all grading methods. We absolutely agree to the conclusion of the authors. The PREPARE score only includes simple preoperatively available diagnostic parameters which enables sufficient risk stratification.[1]The authors suggested that risk stratification of patients undergoing pancreatic surgery can not enable accurate risk prediction without adding intraoperative parameters like pancreatic texture or pancreatic duct diameter. In this point we have our own opinions. Several pancreas specific risk scores including intraoperative parameters like texture of the parenchyma have been published.[2-5]In most of them, high accuracy and sufficient risk prediction were reported. But this postoperative risk stratification does not enable a preoperative optimization of the patient’s health status. Any scoring system should offer the possibility of improvement in clinical practice. The PREPARE score highlights options for management before surgery. In reality, postoperative risk stratification without preoperative evaluations is of less clinical importance. This may be one of the reasons why most of the published scores have not been validated by other centres of pancreatic surgery so far. On the other hand, we have to mention that the PREPARE score mandates further verification and possible future modification of the selection and weighting of variables.

In summary, the article “External validation of PREPARE score in Turkish patients who underwent pancreatic surgery” confirms the accuracy and sufficient risk stratification of the PREPARE score. Furthermore, it demonstrates that external validations of the PREPARE score by other pancreatic centers are urgently needed.

Matthias Reeh and Faik G Uzunoglu

University Hospital Hamburg Eppendorf,

General, Visceral and Thoracic Surgery,

Martinistr. 52, 20246 Hamburg,

Germany

Email: mreeh@uke.de

References

1 Uzunoglu FG, Reeh M, Vettorazzi E, Ruschke T, Hannah P,Nentwich MF, et al. Preoperative pancreatic resection (PREPARE) score: a prospective multicenter-based morbidity risk score. Ann Surg 2014;260:857-864.

2 Braga M, Capretti G, Pecorelli N, Balzano G, Doglioni C, Ariotti R, et al. A prognostic score to predict major complications after pancreaticoduodenectomy. Ann Surg 2011;254:702-708.

3 Greenblatt DY, Kelly KJ, Rajamanickam V, Wan Y, Hanson T, Rettammel R, et al. Preoperative factors predict perioperative morbidity and mortality after pancreaticoduodenectomy. Ann Surg Oncol 2011;18:2126-2135.

4 Brooks MJ, Sutton R, Sarin S. Comparison of surgical risk score, POSSUM and p-POSSUM in higher-risk surgical patients. Br J Surg 2005;92:1288-1292.

5 Knight BC, Kausar A, Manu M, Ammori BA, Sherlock DJ, O’ Reilly DA. Evaluation of surgical outcome scores according to ISGPS definitions in patients undergoing pancreatic resection. Dig Surg 2010;27:367-374.

Published online January 7, 2016.

Metings and Courses

Announcements for this section should be submitted in the correct format at least 3 months before the required date of publication. This list is provided as a service to readers; inclusion does not imply endorsement by the Hepatobiliary & Pancreatic Diseases International.

Section editor

Shui-Ying Lei

Email: hbpdint@126.com

February, 2016

16th annual minimally invasive surgery symposium (MISS)

February 23-26, 2016; Las Vegas, USA

The 16th annual minimally invasive surgery symposium (MISS) will offer compelling lectures, surgical video presentations, and lively discussion and debate by worldrenowned experts on advanced laparoscopic techniques for managing metabolic disorders, hernia, foregut and diseases of the colon. Attending this symposium is: 1) to learn about the latest advances in minimally invasive surgery from the world’s leading experts; 2) to interact with high level surgeons in an informal atmosphere conducive to peer-to-peer learning; 3) to earn up to 31.5 CME credits (including optional MOC self-assessment credit) in minimally invasive surgery for colon, hernia, foregut and metabolic diseases; and 4) to engage in lively debate on controversial subjects and new techniques. For more information, please visit: http://www.misscme.org/site/Default.aspx.

2nd fetal medicine, pediatric gastro, hepatology & nutrition conference

February 25-27, 2016; Abu Dhabi, United Arab Emirates This 3-day conference will provide the latest current practices in fetal and paediatric medicine, as well as learn about future perspectives for treatment. For more information, please visit: http://www.menaconf.com/index.php?cmd=cms__view&article_id=843.

April

AACR annual meeting 2016

April 16-20, 2016; Ernest N. Morial Convention Center, New Orleans, Louisiana, USA

The AACR annual meeting highlights the best cancer science and medicine from institutions all over the world. Attendees are invited to stretch their boundaries, form collaborations, attend sessions outside their own areas of expertise, and learn how to apply exciting new concepts, tools, and techniques to their own research. Program committee chairperson is Scott A. Armstrong, Memorial Sloan Kettering Cancer Center, New York, New York, USA. For more information, please visit: http://www.aacr.org/Meetings/Pages/MeetingDetail. aspx?EventItemID=63#.VfFHZ_nvPGg.

May

McMaster international review course in internal medicine (MIRCIM)

May 6-7, 2016; Krakow, Poland

This course is organized by McMaster University Department of Medicine, Jagiellonian University Medical College, and the Polish Society of Internal Medicine. Co-chairs of the Organizing Committees are Akbar Panju, MB ChB FRCPC FRCP (Edin), FRCP (Glasg) FACP, McMaster University, Canada; Paul O’Byrne, MB FRCP(C) FRSC, Chair, Department of Medicine, Mc-Master University, Canada; and Piotr Gajewski, MD PhD FACP, Polish Society of Internal Medicine, Medycyna Praktyczna. The aim of MIRCIM 2016 is an accessible presentation of the most practical, up-to-date, evidence-based knowledge useful in everyday practice. The presentations will provide a unique opportunity to discuss the most relevant statements presented in the latest guidelines, with take-home messages for immediate implementation in your patients’ care. The broad array of issues analysed during the lectures and panel discussions will undoubtedly benefit a wide audience of general internists, subspecialists, hospitalists, family physicians, residents and fellows in training specialising in internal medicine. The sheer diversity of topics makes the McMaster Course a uniquely rich educational experience, providing the basis for a holistic approach to challenges faced today by medical professionals around the world. For more information, please visit: http:// www.globaleventslist.elsevier.com/events/2016/05/mcmaster-international-review-course-in-internal-medicine-mircim/.

NASH: Beyond the acronym: certainties and clinical dilemmas

May 12-14, 2016; Riga, Latvia

Scientific organizing committees are Jean-Francois Dufour, Bern, Switzerland; Manuel Romero-Gomez, Sevilla, Spain; and Vlad Ratziu, Paris, France. Topics covered include NASH, epidemiology, disease history and prognostic, diagnosis progress, and disease management. The conference will be an excellent place todiscuss epidemiology and pros and cons for population screening together with the analysis of individual risk factors from genes to environment. NAFLD as a systemic disease is associated with several pathological conditions from cardiovascular to kidneys and lung diseases. Diagnostic methods would be addressed, including liver histology as well as non-invasive methods. Defining safe and accurate non-invasive diagnostic methods are an unmet need that is mandatory to resolve for the improvement of knowledge and management of this entity. Mechanism of disease progression could allow us to look for new therapeutic targets. Lastly, patient selection for therapeutic interventions starting with approaches to promote weight loss using diet and physical exercise interventions to bariatric surgery will be reviewed. In non-responders patients, emerging pharmacologic options would fill the gap to increase success rate in NASH resolution. For further information, please visit: https:// events.easl.eu/EventPortal/Information/MR/HOME. aspx.

ILTS workshop: liver transplantation in HCV positive recipients

May 19-20, 2016; San Francisco, CA, USA

The ILTS workshop and consensus conference will take place the 2 days prior to digestive diseases week (DDW) being held in San Diego, CA, so any delegates would be able to attend this workshop and conference as well as DDW. For further information, please contact: Norah Terrault, MD, MPH, Consensus Co-Chair, Professor of Medicine and Surgery, Director, Viral Hepatitis Center, Division of Gastroenterology, University of California San Francisco, San Francisco, California, Norah. Email: Terrault@ucsf.edu; Or Lisa D. Pedicone, PhD, Consensus Committee Consultant, Executive Vice President, Clinical Affairs, Focus Medical Communications, Parsippany, New Jersey 07054, USA. Tel: +973-520-1822; Email: lpedicone@focusmeded.com.

Digestive Disease Week? (DDW)

May 21-24, 2016; San Diego, USA

DDW is considered the largest and most prestigious meeting in the world for the GI professional. Every year it attracts more than 15 000 physicians, researchers and academics from around the world who desire to stay up-to-date in the field. The meeting is the year’s best opportunity to learn about the latest advances in gastroenterology, hepatology, endoscopy and gastrointestinal surgery, prevention, diagnosis and treatment of digestive disorders, and cutting-edge technological advances. For more information, visit: www.ddw.org.

June

Liver fibrosis: the next goal of targeted therapy?

June 17-18, 2016; Porto, Portugal

Scientific organizing committees are Sophie Lotersztajn, Paris, France; Massimo Pinzani, London, UK; and Christian Trautwein, Aachen, Germany. The conference is dedicated to all the current key areas of research in liver fibrogenesis and will focus on a number of open issues requiring further scientific efforts. The role of genetic/epigenetic factors and of the immune system, and the reversibility of fibrosis and methodologies for the identification of more reliable targets for drug development will represent some of the hot topics to be covered. Young scientists are particularly encouraged to participate and will have the opportunity to present their original results during a dedicated session. The format is intended to generate active interactions and discussion between basic scientists and clinicians, and to foster future collaborative efforts to better understand the pathogenesis of tissue fibrosis in chronic liver disease. Ultimately, to improve patient management. For further information, please visit: https://events.easl.eu/Event-Portal/Information/EventInformation.aspx?EventInfor mationPageCode=HOME&EventCode=MONP.

Cost-effectiveness in liver disorders: from prevention to transplantation

June 23-25, 2016; Budapest, Hungary

At this Budapest meeting, cost-effectiveness of different liver diseases will be analyzed by medical and health-economy experts to help physicians, insurance companies and decision makers in rational allocation of resources. Main topics include health benefit/costeffectiveness of primary prevention (vaccination, diet, environmental factors); screening and surveillance (viral hepatitis, NAFLD, HCC); diagnostic algorithms (enzyme elevation, nodules, rare liver diseases); medical therapy (HCV, HBV, HCC, NFLD, NASH, cirrhosis etc.); surgical/invasive therapy (TIPS, RFA, transplantation); burden of liver diseases from scientific; and payers’ perspectives. For further information, please visit: http://www.celdbudapest.eu/.

(doi:10.1016/S1499-3872(16)60055-3) 10.1016/S1499-3872(16)60056-5) 10.1016/S1499-3872(16)60060-7)