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Rajesh J, Sorensen J, McNamara DA. Composite quality measures of abdominal surgery at a population level: systematic review. BJS Open 2023; 7:zrad082. [PMID: 37931232 PMCID: PMC10627522 DOI: 10.1093/bjsopen/zrad082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 06/14/2023] [Accepted: 07/15/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND Measurement of surgical quality at a population level is challenging. Composite quality measures derived from administrative and clinical information systems could support system-wide surgical quality improvement by providing a simple metric that can be evaluated over time. The aim of this systematic review was to identify published studies of composite measures used to assess the overall quality of abdominal surgical services at a hospital or population level. METHODS A search was conducted in PubMed and MEDLINE for references describing measurement instruments evaluating the overall quality of abdominal surgery. Instruments combining multiple process and quality indicators into a single composite quality score were included. The identified instruments were described in terms of transparency, justification, handling of missing data, case-mix adjustment, scale branding and choice of weight and uncertainty to assess their relative strengths and weaknesses (PROSPERO registration: CRD42022345074). RESULTS Of 5234 manuscripts screened, 13 were included. Ten unique composite quality measures were identified, mostly developed within the past decade. Outcome measures such as mortality rate (40 per cent), length of stay (40 per cent), complication rate (60 per cent) and morbidity rate (70 per cent) were consistently included. A major challenge for all instruments is the reliance of valid administrative data and the challenges of assigning appropriate weights to the underlying instrument components. A conceptual framework for composite measures of surgical quality was developed. CONCLUSION None of the composite quality measures identified demonstrated marked superiority over others. The degree to which administrative and clinical data influences each composite measure differs in important ways. There is a need for further testing and development of these measures.
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Affiliation(s)
- Joel Rajesh
- Healthcare Outcomes Research Centre (HORC), Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | - Jan Sorensen
- Healthcare Outcomes Research Centre (HORC), Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | - Deborah A McNamara
- National Clinical Programme in Surgery (NCPS), Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland
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Marcus H, Nikolaos K, Patrik L, Oskar S, Stefan L, Stefan G, Ernesto S, Poya G. Post-pancreatectomy Acute Pancreatitis in Distal Pancreatectomies - a Rare Bird According to the New Definition. J Gastrointest Surg 2023; 27:1640-1649. [PMID: 37308735 PMCID: PMC10412659 DOI: 10.1007/s11605-023-05721-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 05/20/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND Post-pancreatectomy acute pancreatitis (PPAP) is a recently identified clinical condition characterized by sustained elevated serum amylase levels for at least 48 h post-operatively, consistent radiological findings, and relevant clinical features. The purpose of this study was to determine the frequency of PPAP after DP, to investigate the rate of major complications in patients with sustained or transiently elevated serum amylase activity, and to explore the usability of CT as a prerequisite for the diagnosis of PPAP. METHODS This retrospective single-center observational study included consecutive patients 18 years or older who underwent DP at Karolinska University Hospital between 2008 and 2020. The two serum amylase levels on post-operative days (POD) 1 and 2 were correlated with post-operative major complications by logistic regression analyses. RESULTS Of the 403 patients who underwent DP, 14% (n = 58) had sustained elevated serum amylase levels according to PPAP criteria, and 31% (n = 126) had transiently elevated serum amylase levels on either POD1 or POD2. Of the patients with sustained elevated levels, 45% (n = 26) developed major complications, but less than 2% (n = 1) showed imaging findings consistent with acute pancreatitis. Of the 126 patients who exhibited only transiently elevated serum amylase on either POD1 or POD2, 38% (n = 48) developed major complications. The frequency of PPAP was 0.25% (n = 1). CONCLUSION These findings indicate that PPAP after DP is rare and that computed tomography has limited usability for diagnosing PPAP. The findings also suggest that transiently elevated serum amylase may be an early indicator of acute pancreatitis, especially when peaked.
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Affiliation(s)
- Holmberg Marcus
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden.
- Department of Surgery, Capio St Görans Hospital, Stockholm, Sweden.
| | - Kartalis Nikolaos
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
- Department of Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - Larsson Patrik
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
- Department of Upper Gastrointestinal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Swartling Oskar
- Department of Upper Gastrointestinal Diseases, Karolinska University Hospital, Stockholm, Sweden
- Division of Clinical Epidemiology, Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Linder Stefan
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
- Department of Upper Gastrointestinal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Gilg Stefan
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
- Department of Upper Gastrointestinal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Sparrelid Ernesto
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
- Department of Upper Gastrointestinal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Ghorbani Poya
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
- Department of Upper Gastrointestinal Diseases, Karolinska University Hospital, Stockholm, Sweden
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Surgical treatment of pancreatic cancer: Currently debated topics on morbidity, mortality, and lymphadenectomy. Surg Oncol 2022; 45:101858. [DOI: 10.1016/j.suronc.2022.101858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 09/07/2022] [Accepted: 09/26/2022] [Indexed: 11/21/2022]
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Weinberg L, Ratnasekara V, Tran AT, Kaldas P, Neal-Williams T, D’Silva MR, Hua J, Yip S, Lloyd-Donald P, Fletcher L, Ma R, Perini MV, Nikfarjam M, Lee DK. The Association of Postoperative Complications and Hospital Costs Following Distal Pancreatectomy. Front Surg 2022; 9:890518. [PMID: 35711711 PMCID: PMC9195500 DOI: 10.3389/fsurg.2022.890518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 04/13/2022] [Indexed: 12/09/2022] Open
Abstract
Background Understanding the financial implications associated with the complications post-distal pancreatectomy (DP) may be beneficial for the future optimisation of postoperative care pathways and improved cost-efficiency. The primary outcome of this retrospective study was the characterisation of the additional cost associated with postoperative complications following DP. The secondary outcome was the estimation of the prevalence, type and severity of complications post-DP and the determination of which complications were associated with higher costs. Methods Postoperative complications were retrospectively examined for 62 adult patients undergoing distal pancreatectomy at an Australian university hospital between January 2012 and July 2021. Complications were defined and graded using the Clavien–Dindo (CVD) classification system. In-hospital cost of index admission was calculated using an activity-based costing methodology and was reported in US dollars at 2021 rates. Regression modelling was used to investigate the relationships among selected perioperative variables, complications and costs. Results 45 patients (72.6%) experienced one or more postoperative complications. The median (IQR) hospital cost in US dollars was 31.6% greater in patients who experienced complications compared to those who experienced no complications ($40,717.8 [27,358.0–59,834.3] vs. $30,946.9 [23,910.8–46,828.1]). Costs for patients with four or more complications were 43.5% higher than for those with three or fewer complications (p = 0.015). Compared to patients with no complications, the median hospital costs increased by 17.1% in patients with minor complications (CVD grade I/II) and by 252% in patients who developed major complication (i.e., CVD grade III/IV) complications. Conclusion Postoperative complications are a key target for cost-containment strategies. Our findings demonstrate a high prevalence of postoperative complications following distal pancreatectomy with number and severity of postoperative complications being associated with increased hospital costs. (Registered in the Australian New Zealand Clinical Trials Registry [No. ACTRN12622000202763]).
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Affiliation(s)
- Laurence Weinberg
- Department of Anaesthesia, Austin Health, Heidelberg, Australia
- Department of Critical Care, The University of Melbourne, Austin Health, Heidelberg, Australia
- Department of Surgery, The University of Melbourne, Austin Health, Heidelberg, Australia
- Correspondence: Laurence Weinberg
| | | | - Anthony T. Tran
- Department of Anaesthesia, Austin Health, Heidelberg, Australia
| | - Peter Kaldas
- Department of Surgery, The University of Melbourne, Austin Health, Heidelberg, Australia
| | | | | | - Jackson Hua
- Department of Anaesthesia, Austin Health, Heidelberg, Australia
| | - Sean Yip
- Department of Anaesthesia, Austin Health, Heidelberg, Australia
| | | | - Luke Fletcher
- Department of Anaesthesia, Austin Health, Heidelberg, Australia
- Data Analytics Research and Evaluation (DARE) Centre, Austin Health, Heidelberg, Australia
| | - Ronald Ma
- Business Intelligence Unit, Austin Health, Heidelberg, Australia
| | - Marcos V. Perini
- Department of Surgery, The University of Melbourne, Austin Health, Heidelberg, Australia
| | - Mehrdad Nikfarjam
- Department of Surgery, The University of Melbourne, Austin Health, Heidelberg, Australia
| | - Dong-Kyu Lee
- Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
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Pausch TM, Bartel M, Cui J, Aubert O, Mitzscherling C, Liu X, Gesslein B, Schuisky P, Kommoss FKF, Bruckner T, Golriz M, Mehrabi A, Hackert T. SmartPAN: in vitro and in vivo proof-of-safety assessments for an intra-operative predictive indicator of postoperative pancreatic fistula. Basic Clin Pharmacol Toxicol 2022; 130:542-552. [PMID: 35040273 DOI: 10.1111/bcpt.13708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 12/07/2021] [Accepted: 01/12/2022] [Indexed: 12/01/2022]
Abstract
Pancreatic surgery is complicated by untreated fluid leakage, but no tenable techniques exist to detect and close leakage sites during surgery. A novel hydrogel called SmartPAN has been developed to meet this need and is here assessed for safety before trials on human patients. Firstly, resazurin assays were used to test the cytotoxic effects of SmartPAN's active bromothymol blue (BTB) indicator and its solution of phosphate-buffered saline (PBS) on normal (HPDE: Human Pancreatic Duct Epithelial) or carcinomic (FAMPAC) human pancreatic cells. Cells incubated with BTB showed no significant reduction in cell viability below threshold safety levels. However, PBS had a mild cytotoxic effect on FAMPAC cells. Secondly, SmartPAN's pathological effects were evaluated in vivo by applying 4 mL SmartPAN to a porcine (Sus scrofa domesticus) model of pancreatic resection. There were no significant differences in macroscopic and microscopic pathologies between pigs treated with SmartPAN or saline. Thirdly, measurements using HPLC-MS/MS demonstrate that BTB does not cross into the bloodstream and was eliminated from the body within two days of surgery. Overall, SmartPAN appears safe in the short-term and ready for first-in-human trials because its components are either biocompatible or quickly neutralized by dilution and drainage.
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Affiliation(s)
- Thomas M Pausch
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Marc Bartel
- Institute of Legal and Traffic Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Jiaqu Cui
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Ophelia Aubert
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Clara Mitzscherling
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Xinchun Liu
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | | | | | - Felix K F Kommoss
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Thomas Bruckner
- Institute of Legal and Traffic Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Mohammad Golriz
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
| | - Thilo Hackert
- Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Germany
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Lequeu JB, Cottenet J, Facy O, Perrin T, Bernard A, Quantin C. Failure to rescue in patients with distal pancreatectomy: a nationwide analysis of 10,632 patients. HPB (Oxford) 2021; 23:1410-1417. [PMID: 33622649 DOI: 10.1016/j.hpb.2021.02.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 02/01/2021] [Accepted: 02/02/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND FTR appears as a major cause of postoperative mortality (POM). Hospital volume has an impact on FTR in pancreatic surgery but no study has investigated this relationship more specifically in DP. METHODS We analysed patients with DP between 2009 and 2018 through a nationwide database. FTR definition was mortality among patients who experiment major complications. The cutoff between high and low volume centers was 20 pancreatectomies per year. RESULTS Some 10,632 patients underwent DP, 5048 (47.5%) were operated in 602 (95.4%) low volume centers and 5584 (52.5%) in 29 (4.6%) high volume centers. Overall FTR occurred in 11.2% of patients and was significantly reduced in high volume centers compared to low volume centers (10.2% vs 12.5%, p = 0.047). In multivariate analysis, surgery in a high volume center was a protective factor for POM (OR = 0.570, CI95% [0.505-0.643], p < 0.001) and also for FTR (OR = 0.550, CI95% [0.486-0.630], p < 0.001). CONCLUSION Hospital volume has a positive impact on FTR in DP. Patients with higher risk of FTR are men, with high modified Charlson comorbidity index, malignant conditions and open procedures.
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Affiliation(s)
- Jean-Baptiste Lequeu
- Dijon University Hospital, Department of Digestive Surgical Oncology, Dijon F-21000, France.
| | - Jonathan Cottenet
- Dijon University Hospital, Clinical Epidemiology/Clinical Trials Unit, Clinical Investigation Center, Dijon F-21000, France
| | - Olivier Facy
- Dijon University Hospital, Department of Digestive Surgical Oncology, Dijon F-21000, France
| | - Thomas Perrin
- Dijon University Hospital, Department of Digestive Surgical Oncology, Dijon F-21000, France
| | - Alain Bernard
- Dijon University Hospital, Department of Thoracic Surgery, Dijon F-21000, France
| | - Catherine Quantin
- Dijon University Hospital, Clinical Epidemiology/Clinical Trials Unit, Clinical Investigation Center, Dijon F-21000, France
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Pausch TM, Mitzscherling C, Aubert O, Liu X, Gesslein B, Bruckner T, Kommoss FKF, Golriz M, Mehrabi A, Hackert T. Applying an intraoperative predictive indicator for postoperative pancreatic fistula: randomized preclinical trial. Br J Surg 2021; 108:235-238. [PMID: 33608727 DOI: 10.1093/bjs/znaa115] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 11/05/2020] [Indexed: 01/08/2023]
Abstract
Leaking pancreatic fluid can contribute to postoperative pancreatic fistula (POPF), which can complicate pancreatic surgery. Surgeons lack reliable tools to identify pancreatic leaks, so a novel hydrogel indicator called SmartPAN was developed for intraoperative application. In this preclinical efficacy assessment study, SmartPAN was capable of detecting sites associated with biochemical leak and POPF-related symptoms, thereby guiding effective closure. Thus, SmartPAN may help to reduce POPF development in upcoming clinical trials.
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Affiliation(s)
- T M Pausch
- Department of General, Visceral, and Transplant Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - C Mitzscherling
- Department of General, Visceral, and Transplant Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - O Aubert
- Department of General, Visceral, and Transplant Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - X Liu
- Department of General, Visceral, and Transplant Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | | | - T Bruckner
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - F K F Kommoss
- Institute of Pathology, University of Heidelberg, Heidelberg, Germany
| | - M Golriz
- Department of General, Visceral, and Transplant Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - A Mehrabi
- Department of General, Visceral, and Transplant Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - T Hackert
- Department of General, Visceral, and Transplant Surgery, Heidelberg University Hospital, Heidelberg, Germany
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Risk Factors for Clinically Relevant Postoperative Pancreatic Fistula (CR-POPF) after Distal Pancreatectomy: A Single Center Retrospective Study. Can J Gastroenterol Hepatol 2021; 2021:8874504. [PMID: 33542910 PMCID: PMC7840268 DOI: 10.1155/2021/8874504] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 11/15/2020] [Accepted: 01/07/2021] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES Clinically relevant postoperative pancreatic fistula (CR-POPF) is the considerable contributor to major complications after pancreatectomy. The purpose of this study was to evaluate the potential risk factor contributing to CR-POPF following distal pancreatectomy (DP) and discuss the risk factors of pancreatic fistula in order to interpret the clinical importance. METHODS In this retrospective study, 263 patients who underwent DP at Ningbo Medical Center Li Huili Hospital between January 2011 and January 2020 were reviewed in accordance with relevant guidelines and regulations. Patients' demographics and clinical parameters were evaluated using univariate and multivariate analyses to identify the risk factors contributing to CR-POPF. P < 0.05 was considered statistically significant. RESULTS In all of the 263 patients with DP, pancreatic fistula was the most common surgical complication (19.0%). The univariate analysis of 18 factors showed that the patients with a malignant tumor, soft pancreas, and patient without ligation of the main pancreatic duct were more likely to develop pancreatic fistula. However, on multivariate analysis, the soft texture of the pancreas (OR = 2.381, 95% CI = 1.271-4.460, P=0.001) and the ligation of the main pancreatic duct (OR = 0.388, 95% CI = 0.207-0.726, P=0.002) were only an independent influencing factor for CR-POPF. CONCLUSIONS As a conclusion, pancreatic fistula was the most common surgical complication after DP. The soft texture of the pancreas and the absence of ligation of the main pancreatic duct can increase the risk of CR-POPF.
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Leon P, Giannone F, Belfiori G, Falconi M, Crippa S, Boggi U, Menonna F, Al Sadairi AR, Piardi T, Sulpice L, Gardini A, Sega V, Chirica M, Ravazzoni F, Giannandrea G, Pessaux P, de Blasi V, Navarro F, Panaro F. The Oncologic Impact of Pancreatic Fistula After Distal Pancreatectomy for Pancreatic Ductal Adenocarcinoma of the Body and the Tail: A Multicenter Retrospective Cohort Analysis. Ann Surg Oncol 2020; 28:3171-3183. [PMID: 33156465 DOI: 10.1245/s10434-020-09310-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 10/13/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The aim of this study was to assess the impact of clinically relevant postoperative pancreatic fistula (CR-POPF) on patient disease-specific survival and recurrence after curative distal pancreatectomy (DP) for pancreatic cancer. DESIGN This was a retrospective case-control analysis. METHODS We examined the data of adult patients with a diagnosis of pancreatic ductal adenocarcinoma (PDAC) of the body and tail of the pancreas undergoing curative DP, over a 10-year period in 12 European surgical departments, from a prospectively implemented database. RESULTS Among the 382 included patients, 283 met the strict inclusion criteria; 139 were males (49.1%) and the median age of the entire population was 70 years (range 37-88). A total of 121 POPFs were observed (42.8%), 42 (14.9%) of which were CR-POPFs. The median follow-up period was 24 months (range 3-120). Although poorer in the POPF group, overall survival (OS) and disease-free survival (DFS) did not differ significantly between patients with and without CR-POPF (p = 0.224 and p = 0.165, respectively). CR-POPF was not significantly associated with local or peritoneal recurrence (p = 0.559 and p = 0.302, respectively). A smaller percentage of patients benefited from adjuvant chemotherapy after POPF (76.2% vs. 83.8%), but the difference was not significant (p = 0.228). CONCLUSIONS CR-POPF is a major complication after DP but it did not affect the postoperative therapeutic path or long-term oncologic outcomes. CR-POPF was not a predictive factor for disease recurrence and was not associated with an increased incidence of peritoneal or local relapse. TRIAL REGISTRATION ClinicalTrials.gov ID: NCT04348084.
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Affiliation(s)
- Piera Leon
- Department of Surgery/Division of HBP Surgery and Transplantation, "Saint Eloi" Montpellier University Hospital, Montpellier, France.
| | - Fabio Giannone
- Department of Surgery/Division of HBP Surgery and Transplantation, "Saint Eloi" Montpellier University Hospital, Montpellier, France
| | - Giulio Belfiori
- "San Raffaele" IRCCS Hospital, Università Vita - Salute, Milan, Italy
| | - Massimo Falconi
- "San Raffaele" IRCCS Hospital, Università Vita - Salute, Milan, Italy
| | - Stefano Crippa
- "San Raffaele" IRCCS Hospital, Università Vita - Salute, Milan, Italy
| | - Ugo Boggi
- "Cisanello" University Hospital, Pisa, Italy
| | | | | | | | | | | | | | | | | | | | | | - Vito de Blasi
- Hospital Centre of Luxembourg, Luxembourg City, Luxembourg
| | - Francis Navarro
- Department of Surgery/Division of HBP Surgery and Transplantation, "Saint Eloi" Montpellier University Hospital, Montpellier, France
| | - Fabrizio Panaro
- Department of Surgery/Division of HBP Surgery and Transplantation, "Saint Eloi" Montpellier University Hospital, Montpellier, France
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Andrianello S, Bannone E, Marchegiani G, Malleo G, Paiella S, Esposito A, Salvia R, Bassi C. Characterization of postoperative acute pancreatitis (POAP) after distal pancreatectomy. Surgery 2020; 169:724-731. [PMID: 33268073 DOI: 10.1016/j.surg.2020.09.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/25/2020] [Accepted: 09/02/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Postoperative acute pancreatitis has recently been reported as a specific complication after pancreatoduodenectomy. The aim of this study was to characterize postoperative acute pancreatitis after distal pancreatectomy. METHODS We analyzed the outcomes retrospectively of 368 patients who underwent distal pancreatectomies during the period January 2016 to December 2019. Postoperative acute pancreatitis was defined as an increase of serum amylase activity greater than our laboratory normal upper limit on postoperative days 0 to 2. We assessed the incidence of postoperative acute pancreatitis after distal pancreatectomy and examined possible predictors of postoperative acute pancreatitis and relationships of postoperative acute pancreatitis with postoperative pancreatic fistula. RESULTS The rates of postoperative acute pancreatitis and postoperative pancreatic fistula after distal pancreatectomy were 67.9% and 28.8%, respectively. Patients who developed postoperative acute pancreatitis experienced an increased rate of severe morbidity (18.4 vs 9.3%; P = .030). Neoadjuvant therapy (odds ratio 0.28, 0.09-0.85; P = .025), age ≥ 65 y (odds ratio 0.34, 0.13-0.85; P = .020), duct size (odds ratio 0.02, 0.002-0.47; P = .013), pancreatic thickness (odds ratio 3.4, 1.29-8.9; P = .013), resection at the body-tail level (odds ratio 4.3, 1.15-23.19; P = .041), and neuroendocrine histology (odds ratio 1.14, 1.06-3.90; P = .013) were independent predictors of postoperative acute pancreatitis. Furthermore, postoperative acute pancreatitis was an independent predictor of postoperative pancreatic fistula (odds ratio 5.8, 2.27-15.20; P < .001). Postoperative pancreatic fistula occurred in 37% of patients who developed postoperative acute pancreatitis. Patients developing postoperative acute pancreatitis alone demonstrated a statistically significantly increased rate of biochemical leakage and bacterial contamination in the peripancreatic drainage fluid. CONCLUSION Postoperative acute pancreatitis is a frequent event after distal pancreatectomy and, despite its close association with postoperative pancreatic fistula, evidently represents a separate phenomenon. A universally accepted definition of postoperative acute pancreatitis that applies to all types of pancreatic resections is needed, because it may identify patients at greater risk for additional morbidity immediately after pancreatic resections.
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Affiliation(s)
- Stefano Andrianello
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Elisa Bannone
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giovanni Marchegiani
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Giuseppe Malleo
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Salvatore Paiella
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Alessandro Esposito
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Claudio Bassi
- Department of General and Pancreatic Surgery-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy.
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Tahkola K, Väyrynen V, Kellokumpu I, Helminen O. Critical evaluation of quality of hepatopancreatic surgery in a medium-volume center in Finland using the Accordion Severity Grading System and the Postoperative Morbidity Index. J Gastrointest Oncol 2020; 11:724-737. [PMID: 32953156 DOI: 10.21037/jgo.2020.04.03] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background Hepatopancreatobiliary surgery is prone to complications. Methods are needed to monitor surgical outcomes and enable comparison between institutions. Methods Complications were collected prospectively and reviewed using the modified Accordion Severity Grading System (MASGS) and the Postoperative Morbidity Index (PMI). Results This study included 527 consecutive patients receiving either pancreatic or liver resection in 2000-2017 in Central Finland Central Hospital. The PMI was 0.177 for all patients, and 0.192, 0.094, 0.285, and 0.129 for patients receiving major pancreatic (n=218), minor pancreatic (n=93), major liver (n=73), and minor liver (n=143) resection, respectively. The rates of postoperative pancreatic fistula (POPF) after pancreaticoduodenectomies (n=200) were 6.5% for grade B and 5.5% for grade C; rates for biliary leak were 1.0% (grade A), 2.5% (grade B), and 0.5% (grade C). Similarly, the rates for delayed gastric emptying (DGE) were 2.8% (grade A), 15.6% (grade B), and 3.7% (grade C). Postoperative hepatic dysfunction occurred in 2.3%, major surgical site bleeding in 2.3%, and biloma in 7.9% of patients after liver resection. Ninety-day mortality rates were 3.7% and 1.1% in major and minor pancreatic resections, and 8.2% and 0.7% in major and minor liver resections. Major complications occurred in 13.3% and 3.3% in pancreatic, and 19.2% and 6.3% in liver resections, respectively. Conclusions Major pancreatic and hepatic surgery are associated with significant morbidity and burden in our center, comparable with previous population-based studies. PMI is an informative way to monitor surgical outcomes and enable comparison between institutions.
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Affiliation(s)
- Kyösti Tahkola
- Department of Surgery, Central Finland Central Hospital, Jyväskylä, Finland
| | - Ville Väyrynen
- Department of Surgery, Central Finland Central Hospital, Jyväskylä, Finland
| | - Ilmo Kellokumpu
- Department of Surgery, Central Finland Central Hospital, Jyväskylä, Finland
| | - Olli Helminen
- Department of Surgery, Central Finland Central Hospital, Jyväskylä, Finland
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Pancreatic Fistula and Delayed Gastric Emptying Are the Highest-Impact Complications After Whipple. J Surg Res 2020; 250:80-87. [PMID: 32023494 DOI: 10.1016/j.jss.2019.12.041] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 11/13/2019] [Accepted: 12/28/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND Patients undergoing pancreaticoduodenectomy are at risk for a variety of adverse postoperative events, including generic complications such as surgical site infection (SSI) and procedure-specific complications such as postoperative pancreatic fistula (POPF) and delayed gastric emptying (DGE). Knowing which complications have the greatest effect on these patients can help to maximize the value of quality improvement resources. This study aims to quantify the effect of specific postoperative complications on clinical outcomes and resource utilization after pancreaticoduodenectomy. MATERIALS AND METHODS Patients undergoing pancreaticoduodenectomy between January 2014 and December 2016, who were included in the pancreatectomy-targeted American College of Surgeons National Surgical Quality Improvement Program, were assessed for the development of specific postoperative complications, along with the contributions of these complications toward subsequent clinical outcome and resource utilization. The main outcomes were 30-d end-organ dysfunction, mortality, prolonged hospitalization, nonrounding discharge status, and hospital readmission. Risk-adjusted population attributable fractions were estimated for each complication-outcome pair, with the population attributable fraction representing the anticipated percentage reduction in the outcome where the complication was able to be completely prevented. RESULTS About 10,922 patients undergoing pancreaticoduodenectomy were included for analysis. The most common postoperative complications were DGE (17.3%), POPF (10.1%), incisional SSI (10.0%), and organ/space SSI (6.2%). POPF and DGE were the only complications that demonstrated sizable effects for all clinical and resource utilization outcomes studied. Other complications had sizable effects for only a few of the outcomes or had small effects for all the outcomes. CONCLUSIONS Quality initiatives seeking to minimize the burden imposed by postpancreaticoduodenectomy morbidity should focus on POPF and DGE rather than generic complications.
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Identification of an Optimal Cut-off for Drain Fluid Amylase on Postoperative Day 1 for Predicting Clinically Relevant Fistula After Distal Pancreatectomy: A Multi-institutional Analysis and External Validation. Ann Surg 2019; 269:337-343. [PMID: 28938266 DOI: 10.1097/sla.0000000000002532] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The aim of this study was to investigate the relationship between drain fluid amylase value on the first postoperative day (DFA1) and clinically relevant fistula (CR-POPF) after distal pancreatectomy (DP), and to identify the cut-off of DFA1 that optimizes CR-POPF prediction. BACKGROUND DFA1 is a well-recognized predictor of CR-POPF after pancreatoduodenectomy, but its role in DP is largely unexplored. METHODS DFA1 levels were correlated with CR-POPF in 2 independent multi-institutional sets of DP patients: developmental (n = 338; years 2012 to 2017) and validation cohort (n = 166; years 2006 to 2016). Cut-off choice was based on Youden index calculation, and its ability to predict CR-POPF occurrence was tested in a multivariable regression model adjusted for clinical, demographic, operative, and pathological variables. RESULTS In the developmental set, median DFA1 was 1745 U/L and the CR-POPF rate was 21.9%. DFA1 correlated with CR-POPF with an area under the curve of 0.737 (P < 0.001). A DFA1 of 2000 U/L had the highest Youden index, with 74.3% sensitivity and 62.1% specificity. Patients in the validation cohort displayed different demographic and operative characteristics, lower values of DFA1 (784.5 U/L, P < 0.001), and reduced CR-POPF rate (10.2%, P < 0.001). However, a DFA1 of 2000 U/L had the highest Youden index in this cohort as well, with 64.7% sensitivity and 75.8% specificity. At multivariable analysis, DFA1 ≥2000 U/L was the only factor significantly associated with CR-POPF in both cohorts. CONCLUSION A DFA1 of 2000 U/L optimizes CR-POPF prediction after DP. These results provide the substrate to define best practices and improve outcomes for patients receiving DP.
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Risk Factors and Mitigation Strategies for Pancreatic Fistula After Distal Pancreatectomy: Analysis of 2026 Resections From the International, Multi-institutional Distal Pancreatectomy Study Group. Ann Surg 2019; 269:143-149. [PMID: 28857813 DOI: 10.1097/sla.0000000000002491] [Citation(s) in RCA: 137] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To identify a clinical fistula risk score following distal pancreatectomy. BACKGROUND Clinically relevant pancreatic fistula (CR-POPF) following distal pancreatectomy (DP) is a dominant contributor to procedural morbidity, yet risk factors attributable to CR-POPF and effective practices to reduce its occurrence remain elusive. METHODS This multinational, retrospective study of 2026 DPs involved 52 surgeons at 10 institutions (2001-2016). CR-POPFs were defined by 2016 International Study Group criteria, and risk models generated using stepwise logistic regression analysis were evaluated by c-statistic. Mitigation strategies were assessed by regression modeling while controlling for identified risk factors and treating institution. RESULTS CR-POPF occurred following 306 (15.1%) DPs. Risk factors independently associated with CR-POPF included: age (<60 yrs: OR 1.42, 95% CI 1.05-1.82), obesity (OR 1.54, 95% CI 1.19-2.12), hypoalbuminenia (OR 1.63, 95% CI 1.06-2.51), the absence of epidural anesthesia (OR 1.59, 95% CI 1.17-2.16), neuroendocrine or nonmalignant pathology (OR 1.56, 95% CI 1.18-2.06), concomitant splenectomy (OR 1.99, 95% CI 1.25-3.17), and vascular resection (OR 2.29, 95% CI 1.25-3.17). After adjusting for inherent risk between cases by multivariable regression, the following were not independently associated with CR-POPF: method of transection, suture ligation of the pancreatic duct, staple size, the use of staple line reinforcement, tissue patches, biologic sealants, or prophylactic octreotide. Intraoperative drainage was associated with a greater fistula rate (OR 2.09, 95% CI 1.51-3.78) but reduced fistula severity (P < 0.001). CONCLUSIONS From this large analysis of pancreatic fistula following DP, CR-POPF occurrence cannot be reliably predicted. Opportunities for developing a risk score model are limited for performing risk-adjusted analyses of mitigation strategies and surgeon performance.
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Dasani SS, Simmons KD, Wirtalla CJ, Hoffman RL, Kelz RR. Understanding the Clinical Implications of Resident Involvement in Uncommon Operations. JOURNAL OF SURGICAL EDUCATION 2019; 76:1319-1328. [PMID: 30979651 DOI: 10.1016/j.jsurg.2019.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 02/10/2019] [Accepted: 03/17/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE The objective of this study was to examine uncommon operations in greater detail given that the outcomes of uncommon operations are largely understudied. This study examines the incidence of postoperative events and the role of the resident following uncommon operations. DESIGN We identified uncommon general surgical operations using the ACS National Surgical Quality Improvement Program Participant Use file (2008-2011). Death or serious morbidity (DSM) within 30 days of the operation was the primary outcome of interest. Failure to rescue (FTR) and prolonged operative time (PRopt) were evaluated as secondary outcome measures. PRopt was defined as ≥90 percentile of operative time for each procedure type. Independent multivariate logistic regression models were generated to examine the impact of these descriptors on the outcomes of interest. SETTING/PARTICIPANTS The dataset utilized was the United States National Surgical Quality Improvement Program Participant Use File which leverages data points from over 700 hospitals that range from primary to quaternary care centers. Resident participation was defined as resident involved (RI) or no resident involved (NRI), and stratified by postgraduate year (PGY): 1-3, 4-5, and 6+. RESULTS Resident participant data was available for 21,453 (84.5%) uncommon operations with NRI in 25.4% (5447). With regard to resident participation, PGY1-3 were found in 12.6% (2699), PGY4-5 in 50.4% (10,817), and PGY6+ in 11.6% (2490). The overall observed DSM rate was 28.6% and the observed FTR rate was 5.8%. Overall, there was no difference in DSM by RI status (NRI: 1528; 28.1% vs RI: 4602; 28.8%; p = 0.324); however, PGY level was associated with DSM (PGY1-3: 774, 28.7%, PGY4-5: 3210, 29.7%, PGY6+: 618, 24.8%; p < 0.001). Any RI was associated with a lower rate of FTR (5.1%) when compared to NRI (8.3%, p < 0.001) with decreasing FTR events by increasing PGY (PGY1-3: 6.4%, PGY4-5: 5.2%, PGY6+: 3.3%; p < 0.001). After adjustment for patient risk factors, any RI remained associated with a lower likelihood of FTR than NRI (odds ratio: 0.65, 95% confidence interval: 0.49-0.87) while only the PGY4-5 and PGY6+ groups were associated with lower likelihood of FTR in comparison to NRI. RI was associated with PRopt in univariate and multivariable analyses. CONCLUSIONS Uncommon operations were associated with substantial DSM. The involvement of PGY4-5 residents was associated with the greatest likelihood of DSM. With increasing PGY of the involved resident, cases with PGY > 5 demonstrated a lower likelihood of risk-adjusted FTR. The explanation for these findings is not clear; however, the involvement of more senior residents in the technical aspects of uncommon operations may lead to improved results.
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Affiliation(s)
- Serena S Dasani
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - K D Simmons
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - C J Wirtalla
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - R L Hoffman
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - R R Kelz
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Søreide K, Olsen F, Nymo LS, Kleive D, Lassen K. A nationwide cohort study of resection rates and short-term outcomes in open and laparoscopic distal pancreatectomy. HPB (Oxford) 2019; 21:669-678. [PMID: 30391219 DOI: 10.1016/j.hpb.2018.10.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 09/10/2018] [Accepted: 10/07/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Distal pancreatectomy (DP) is increasingly done by laparoscopy but data from routine practise are scarce. We describe practise in a national cohort. METHODS Data from the Norwegian Patient Register of all patients undergoing DP from 2012 to 2016. National resection rates were analysed. Short-term outcomes include length of stay, reoperation, readmissions and 90-day mortality. Risk is reported as odds ratio (OR) with 95% confidence interval (c.i.). RESULTS Of 554 procedures, 327 (59%) were laparoscopic. Median age was 66 years (iqr 55-72) and 52% were women. Resection rates increased during the period for all DP (from 1.76 to 2.39 per 100.000/yr), and significantly for laparoscopic DP (adjusted R-square 0.858; P = 0.015). Elderly patients had more resection (r2 = 0.11; P = 0.019). Splenectomy (n = 427; 77%) was less likely with laparoscopy (laparoscopy 72% vs open 84%, respectively; OR 0.64, 95% c.i. 0.42-0.97; P = 0.035). Multivisceral resections occurred more often in open DP (5.3% vs 1.2% for laparoscopy, OR 4.51, 1.44-14.2; P = 0.008). Reoperation occurred in 34 (6%), readmission in 109 (20%), and mortality in 8 (1.4%). Hospital stay was shorter for laparoscopic DP. CONCLUSION Use of DP increases in the population, particularly in the elderly, with use of laparoscopic access and an association with a reduced hospital stay.
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Affiliation(s)
- Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway; Clinical Surgery, Royal Infirmary of Edinburgh and University of Edinburgh, UK; Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Frank Olsen
- Centre for Clinical Documentation and Evaluation (SKDE), Northern Norway Regional Health Authority, Tromsø, Norway
| | - Linn S Nymo
- Department of Gastrointestinal Surgery, University Hospital of Northern Norway, Tromsø, Norway; Institute of Clinical Medicine, The Arctic University of Norway, Tromsø, Norway
| | - Dyre Kleive
- Department of Hepatobiliary and Pancreatic Surgery, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kristoffer Lassen
- Institute of Clinical Medicine, The Arctic University of Norway, Tromsø, Norway; Department of Hepatobiliary and Pancreatic Surgery, Oslo University Hospital, Oslo, Norway
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Daniel F, Tamim H, Hosni M, Ibrahim F, Mailhac A, Jamali F. Validation of day 1 drain fluid amylase level for prediction of clinically relevant fistula after distal pancreatectomy using the NSQIP database. Surgery 2019; 165:315-322. [DOI: 10.1016/j.surg.2018.07.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 07/11/2018] [Accepted: 07/25/2018] [Indexed: 12/19/2022]
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Fisher AV, Fernandes-Taylor S, Schumacher JR, Havlena JA, Wang X, Lawson EH, Ronnekleiv-Kelly SM, Winslow ER, Weber SM, Abbott DE. Analysis of 90-day cost for open versus minimally invasive distal pancreatectomy. HPB (Oxford) 2019; 21:60-66. [PMID: 30076011 DOI: 10.1016/j.hpb.2018.07.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 04/19/2018] [Accepted: 07/03/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Minimally invasive distal pancreatectomy (MIDP) is associated with improved peri-operative outcomes compared to the open approach, though cost-effectiveness of MIDP remains unclear. METHODS Patients with pancreatic tumors undergoing open (ODP), robotic (RDP), or laparoscopic distal pancreatectomy (LDP) between 2012-2014 were identified through the Truven Health MarketScan® Database. Median costs (payments) for the index operation and 90-day readmissions were calculated. Multivariable regression was used to predict associations with log 90-day payments. RESULTS 693 patients underwent ODP, 146 underwent LDP, and 53 RDP. Compared to ODP, LDP and RDP resulted in shorter median length of stay (6 d. ODP vs. 5 d. RDP vs. 4 d. LDP, p<0.01) and lower median payments ($38,350 ODP vs. $34,870 RDP vs. $32,148 LDP, p<0.01) during the index hospitalization. Total median 90-day payments remained significantly lower for both minimally invasive approaches ($40,549 ODP vs. $35,160 RDP vs. $32,797 LDP, p<0.01). On multivariable analysis, LDP and RDP resulted in 90-day cost savings of 21% and 25% relative to ODP, equating to an amount of $8,500-$10,000. CONCLUSION MIDP is associated with >$8,500 in lower cost compared to the open approach. Quality improvement initiatives in DP should ensure that lack of training and technical skill are not barriers to MIDP.
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Affiliation(s)
- Alexander V Fisher
- University of Wisconsin Institute for Surgical Outcomes Research (WiSOR), 600 Highland Avenue, Madison, WI, 53792, United States; University of Wisconsin, Department of Surgery, Division of Surgical Oncology, H4/710 Clinical Science Center, 600 Highland Ave, Madison, WI, 53792, United States
| | - Sara Fernandes-Taylor
- University of Wisconsin Institute for Surgical Outcomes Research (WiSOR), 600 Highland Avenue, Madison, WI, 53792, United States
| | - Jessica R Schumacher
- University of Wisconsin Institute for Surgical Outcomes Research (WiSOR), 600 Highland Avenue, Madison, WI, 53792, United States
| | - Jeffrey A Havlena
- University of Wisconsin Institute for Surgical Outcomes Research (WiSOR), 600 Highland Avenue, Madison, WI, 53792, United States
| | - Xing Wang
- University of Wisconsin Institute for Surgical Outcomes Research (WiSOR), 600 Highland Avenue, Madison, WI, 53792, United States
| | - Elise H Lawson
- University of Wisconsin Institute for Surgical Outcomes Research (WiSOR), 600 Highland Avenue, Madison, WI, 53792, United States
| | - Sean M Ronnekleiv-Kelly
- University of Wisconsin Institute for Surgical Outcomes Research (WiSOR), 600 Highland Avenue, Madison, WI, 53792, United States; University of Wisconsin, Department of Surgery, Division of Surgical Oncology, H4/710 Clinical Science Center, 600 Highland Ave, Madison, WI, 53792, United States
| | - Emily R Winslow
- University of Wisconsin Institute for Surgical Outcomes Research (WiSOR), 600 Highland Avenue, Madison, WI, 53792, United States; University of Wisconsin, Department of Surgery, Division of Surgical Oncology, H4/710 Clinical Science Center, 600 Highland Ave, Madison, WI, 53792, United States
| | - Sharon M Weber
- University of Wisconsin Institute for Surgical Outcomes Research (WiSOR), 600 Highland Avenue, Madison, WI, 53792, United States; University of Wisconsin, Department of Surgery, Division of Surgical Oncology, H4/710 Clinical Science Center, 600 Highland Ave, Madison, WI, 53792, United States
| | - Daniel E Abbott
- University of Wisconsin Institute for Surgical Outcomes Research (WiSOR), 600 Highland Avenue, Madison, WI, 53792, United States; University of Wisconsin, Department of Surgery, Division of Surgical Oncology, H4/710 Clinical Science Center, 600 Highland Ave, Madison, WI, 53792, United States.
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Dumitrascu T, Eftimie M, Aiordachioae A, Stroescu C, Dima S, Ionescu M, Popescu I. Male gender and increased body mass index independently predicts clinically relevant morbidity after spleen-preserving distal pancreatectomy. World J Gastrointest Surg 2018; 10:84-89. [PMID: 30510633 PMCID: PMC6259023 DOI: 10.4240/wjgs.v10.i8.84] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 10/24/2018] [Accepted: 11/04/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To identify risk factors for clinically relevant complications after spleen-preserving distal pancreatectomy (SPDP). No previous studies explored potential predictors of morbidity after SPDP.
METHODS The data of 41 patients who underwent a SPDP in a single surgical center between 2000 and 2015 were retrospectively reviewed from a prospectively maintained electronic database established in our Department of Surgery. The database included demographic, clinical, bioumoral, pathological, intraoperative and postoperative parameters. Uni- and multivariate analyses were performed to assess potential predictors of clinically relevant morbidity. Postoperative morbidity was defined as in-hospital complications and mortality was assessed at 90 d. Clinically relevant morbidity was defined as complication ≥ grade 2 Dindo.
RESULTS Overall morbidity rate was 34.1% (14 patients): grade I (6 patients, 14.6%), grade II (2 patients, 4.8%), grade IIIa (1 patient, 2.4%), and grade IIIb (5 patients, 12.2%). A number of 5 patients (12.2%) required re-laparotomy for postoperative complications. There was no postoperative mortality. Thus, at least one clinically relevant complication occurred in 8 patients (19.5%). Univariate analysis identified male gender (P = 0.034), increased body mass index (P = 0.002) and neuroendocrine pathology (P = 0.013) as statistically significant risk factors. Multivariate analysis identified male gender [odds ratio (OR): 1.29, 95%CI: 1.07-1.55, P = 0.005] and increased body mass index (OR: 23.18, 95%CI: 1.72-310.96, P = 0.018) as the only independent risk factors of clinically relevant morbidity after SPDP.
CONCLUSION Male gender and increased body mass index are independently associated with increased risk of clinically relevant morbidity after SPDP. These findings may assist a surgeon in clinical decision-making to better select patients suitable for SPDP.
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Affiliation(s)
- Traian Dumitrascu
- Department of General Surgery and Liver Transplant, Fundeni Clinical Institute, Bucharest 022328, Romania
| | - Mihai Eftimie
- Department of General Surgery and Liver Transplant, Fundeni Clinical Institute, Bucharest 022328, Romania
| | - Andra Aiordachioae
- Department of General Surgery and Liver Transplant, Fundeni Clinical Institute, Bucharest 022328, Romania
| | - Cezar Stroescu
- Department of General Surgery and Liver Transplant, Fundeni Clinical Institute, Bucharest 022328, Romania
| | - Simona Dima
- Department of General Surgery and Liver Transplant, Fundeni Clinical Institute, Bucharest 022328, Romania
| | - Mihnea Ionescu
- Department of General Surgery and Liver Transplant, Fundeni Clinical Institute, Bucharest 022328, Romania
| | - Irinel Popescu
- Department of General Surgery and Liver Transplant, Fundeni Clinical Institute, Bucharest 022328, Romania
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Ecker BL, McMillan MT, Maggino L, Vollmer CM. Taking Theory to Practice: Quality Improvement for Pancreaticoduodenectomy and Development and Integration of the Fistula Risk Score. J Am Coll Surg 2018; 227:430-438.e1. [DOI: 10.1016/j.jamcollsurg.2018.06.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 06/25/2018] [Accepted: 06/25/2018] [Indexed: 12/19/2022]
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Gavriilidis P, Roberts KJ, Sutcliffe RP. Laparoscopic versus open distal pancreatectomy for pancreatic adenocarcinoma: a systematic review and meta-analysis. Acta Chir Belg 2018; 118:278-286. [PMID: 29996721 DOI: 10.1080/00015458.2018.1492212] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 06/20/2018] [Indexed: 01/14/2023]
Abstract
OBJECTIVES To compare the effectiveness, safety and oncologic adequacy of laparoscopic and open distal pancreatectomy (ODP) for pancreatic adenocarcinoma. METHODS A systematic literature search was performed using EMBASE, Medline, the Cochrane library, and Google Scholar. Meta-analyses were performed using both fixed-effect and random-effect models. A cumulative meta-analysis was performed to track the accumulation of evidence. The power that a new trial of specified samples would give to the present meta-analysis was estimated with simulation-based sample size calculation. RESULTS Patients who underwent laparoscopic distal pancreatectomy (LDP) had significantly smaller tumours [mean difference (MD) = -0.49 (-0.83 to -0.14), p = 0.005], less estimated blood loss [MD = -157.27 (-281.63 to -32.91), p = 0.01], and shorter average hospital stay by two days [MD = -2.35 (-3.1 to -1.59), p < .001] than those who underwent ODP. No significant differences in feasibility, effectiveness, and safety were noted. Cumulative meta-analysis demonstrated that the results were not dominated by a particular study. A new trial with 350 patients in each arm will give a maximum power of 48% to the present meta-analysis. CONCLUSIONS LDP for pancreatic adenocarcinoma provides similar clinical and oncologic outcomes with shorter hospital stay by two days compared to ODP. However, underpowered sample size and smaller tumour size may have influenced the results of laparoscopic surgery. Therefore, an adequately powered randomized controlled trial is needed to shed further light on the appropriateness of this approach.
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Affiliation(s)
- Paschalis Gavriilidis
- a Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery , Queen Elizabeth University Hospitals Birmingham NHS Foundation Trust , Mindelsohn Way , UK
| | - Keith J Roberts
- a Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery , Queen Elizabeth University Hospitals Birmingham NHS Foundation Trust , Mindelsohn Way , UK
| | - Robert P Sutcliffe
- a Department of Hepato-Pancreato-Biliary and Liver Transplant Surgery , Queen Elizabeth University Hospitals Birmingham NHS Foundation Trust , Mindelsohn Way , UK
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Abstract
OPINION STATEMENT Pancreatic cancer surgery is a continuously evolving field. Despite tremendous advances in perioperative outcomes, pancreatic resection is still associated with substantial morbidity, and mortality is not nil. Institutional caseload is a well-established determinant of patient outcomes, and centralization to experienced centers is essential to the safety and oncological appropriateness of the resection. Minimally invasive approaches are increasingly applied for pancreatic resection, even in cancer patients. Nevertheless, the level of evidence in this field remains low. Minimally invasive distal pancreatectomy appears potentially beneficial towards some perioperative outcomes, although its oncological results remain incompletely studied. Data regarding perioperative and oncologic outcomes for minimally invasive pancreaticoduodenectomy (Whipple's resection) is even less mature, but suggest that similar results as the open approach can be achieved in selected, high-volume centers. Conversely, its indiscriminate adoption by inexperienced surgeons and institutions has potential deleterious effects given its steep learning curve. Newer neoadjuvant treatment protocols display enhanced ability to downstage advanced tumors, increasing candidates for potentially curative surgery. Conversely, putative benefits of neoadjuvant treatment in patients with technically resectable tumors have not been reliably demonstrated and its optimal indications remain highly controversial.
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Affiliation(s)
- Laura Maggino
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, USA.,Unit of General and Pancreatic Surgery, Department of Surgery and Oncology-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Charles M Vollmer
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, USA.
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Krige JE, Jonas E, Thomson SR, Kotze UK, Setshedi M, Navsaria PH, Nicol AJ. Resection of complex pancreatic injuries: Benchmarking postoperative complications using the Accordion classification. World J Gastrointest Surg 2017; 9:82-91. [PMID: 28396721 PMCID: PMC5366930 DOI: 10.4240/wjgs.v9.i3.82] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 10/21/2016] [Accepted: 01/18/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To benchmark severity of complications using the Accordion Severity Grading System (ASGS) in patients undergoing operation for severe pancreatic injuries.
METHODS A prospective institutional database of 461 patients with pancreatic injuries treated from 1990 to 2015 was reviewed. One hundred and thirty patients with AAST grade 3, 4 or 5 pancreatic injuries underwent resection (pancreatoduodenectomy, n = 20, distal pancreatectomy, n = 110), including 30 who had an initial damage control laparotomy (DCL) and later definitive surgery. AAST injury grades, type of pancreatic resection, need for DCL and incidence and ASGS severity of complications were assessed. Uni- and multivariate logistic regression analysis was applied.
RESULTS Overall 238 complications occurred in 95 (73%) patients of which 73% were ASGS grades 3-6. Nineteen patients (14.6%) died. Patients more likely to have complications after pancreatic resection were older, had a revised trauma score (RTS) < 7.8, were shocked on admission, had grade 5 injuries of the head and neck of the pancreas with associated vascular and duodenal injuries, required a DCL, received a larger blood transfusion, had a pancreatoduodenectomy (PD) and repeat laparotomies. Applying univariate logistic regression analysis, mechanism of injury, RTS < 7.8, shock on admission, DCL, increasing AAST grade and type of pancreatic resection were significant variables for complications. Multivariate logistic regression analysis however showed that only age and type of pancreatic resection (PD) were significant.
CONCLUSION This ASGS-based study benchmarked postoperative morbidity after pancreatic resection for trauma. The detailed outcome analysis provided may serve as a reference for future institutional comparisons.
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Grossman JG, Fields RC, Hawkins WG, Strasberg SM. Single institution results of radical antegrade modular pancreatosplenectomy for adenocarcinoma of the body and tail of pancreas in 78 patients. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2016; 23:432-41. [PMID: 27207482 DOI: 10.1002/jhbp.362] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 05/19/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND The purpose of this report is to present results of the radical antegrade modular pancreatosplenectomy (RAMPS) procedure in 78 patients from a single center. METHODS Seventy-eight patients had RAMPS procedure over 13 years. A database dealing with RAMPS for adenocarcinoma of the pancreas was constructed so that it could be converted into a set of tables. Each table covered one element of the subject. The database was populated from clinical records of patients who had a RAMPS procedure from 1999 to 2013. RESULTS Fifty-six patients had anterior RAMPS and 22 had posterior RAMPS. Negative tangential margins were obtained in 94% of specimens. Overall the R0 rate was 85%. Mean lymph node count was 20. There were no 30-day or in-hospital mortalities but two patients died within 90 days. Pancreatic fistula and need for postoperative transfusion were the most common complications. Median survival was 24.6 months and 5-year overall actuarial survival was 25.1%. CONCLUSIONS The RAMPS technique resulted in high negative tangential margin rates and good lymph node retrieval. The long-term survival result in 78 patients is probably an accurate reflection of what is possible with this tumor using this technique at this time.
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Affiliation(s)
- Julie G Grossman
- Section of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Washington University in St. Louis, Barnes-Jewish Hospital and Siteman Cancer Center, 4990 Children's Place, Suite 1160, Box 8109, St. Louis, MO, 63110, USA
| | - Ryan C Fields
- Section of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Washington University in St. Louis, Barnes-Jewish Hospital and Siteman Cancer Center, 4990 Children's Place, Suite 1160, Box 8109, St. Louis, MO, 63110, USA
| | - William G Hawkins
- Section of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Washington University in St. Louis, Barnes-Jewish Hospital and Siteman Cancer Center, 4990 Children's Place, Suite 1160, Box 8109, St. Louis, MO, 63110, USA
| | - Steven M Strasberg
- Section of Hepato-Pancreato-Biliary Surgery, Department of Surgery, Washington University in St. Louis, Barnes-Jewish Hospital and Siteman Cancer Center, 4990 Children's Place, Suite 1160, Box 8109, St. Louis, MO, 63110, USA
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McMillan MT, Christein JD, Callery MP, Behrman SW, Drebin JA, Hollis RH, Kent TS, Miller BC, Sprys MH, Watkins AA, Strasberg SM, Vollmer CM. Comparing the burden of pancreatic fistulas after pancreatoduodenectomy and distal pancreatectomy. Surgery 2016; 159:1013-22. [DOI: 10.1016/j.surg.2015.10.028] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 10/09/2015] [Accepted: 10/23/2015] [Indexed: 12/12/2022]
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Abstract
The surgical management of pancreatic diseases is rapidly evolving, encompassing advances in evidence-driven selection of patients amenable for surgical therapy, preoperative risk stratification, refinements in the technical conduct of pancreatic operations, and quantification of postoperative morbidity. These advances have resulted in dramatic reductions in mortality following pancreatic surgery, particularly at high-volume pancreatic centers. Surgical decision making is complex, and requires an intimate understanding of disease pathobiology, host physiology, technical considerations, and evolving trends. This article highlights key developments in the contemporary surgical management of pancreatic diseases.
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Affiliation(s)
- Jashodeep Datta
- Division of Gastrointestinal Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Charles M Vollmer
- Division of Gastrointestinal Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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Onesti JK, Wright GP, Kenning SE, Tierney MT, Davis AT, Doherty MG, Chung MH. Sarcopenia and survival in patients undergoing pancreatic resection. Pancreatology 2016; 16:284-9. [PMID: 26876798 DOI: 10.1016/j.pan.2016.01.009] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 01/19/2016] [Accepted: 01/21/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Recent studies have suggested that lean core muscle area may predict outcomes from major abdominal surgeries. Pancreatic resections have been independently analyzed less frequently. METHODS Pancreatic resections from 2005 to 2012 were reviewed. Sarcopenia was defined as the lowest tertile for lean psoas muscle area (LPMA). Preoperative risk factors, including comorbidities, albumin, weight loss, age and gender, were analyzed with a primary endpoint of overall survival. Secondary endpoints included complications, discharge destination and readmission. RESULTS The study sample of 270 patients had complications in 42% of patients, with 26% developing serious complication. The majority (80%) were discharged home, and 1.9% died in the peri-operative period. The mean length of follow up was 31.2 months (range 0-94), and 37% required at least one readmission. LPMA was predictive of discharge destination for females (p = 0.038). Sarcopenia was predictive of readmission in males, compared to subjects in the second LPMA tertile (HR 0.3; 95% CI: 0.1-0.9). In all male subjects, including a subset with adenocarcinoma, patients with sarcopenia were more likely to die than males in the highest LPMA tertile (HR: 2.6; 95% CI: 1.4-4.8 and HR: 2.4; 95% CI: 1.2-4.9, respectively). In all patients with pancreatic ductal adenocarcinoma, transfusion (HR: 1.9; 95% CI: 1.1-3.4) and positive margins (HR: 2.0; 95% CI: 1.2-3.3) were the only factors predictive of overall survival. CONCLUSIONS Sarcopenia appears to be a predictor of overall survival in male patients undergoing pancreatic resections, but not specifically for patients with pancreatic ductal adenocarcinoma. As prospective data in future studies are identified, sarcopenia may become a useful tool in predicting outcomes.
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Affiliation(s)
- Jill K Onesti
- Department of Surgical Oncology, Mercy Health Physician Partners, Lack Cancer Center, USA.
| | | | | | | | - Alan T Davis
- GRMEP Research Department, USA; MSU Department of Surgery, USA
| | | | - Mathew H Chung
- MSU Department of Surgery, USA; Department of Surgical Oncology, Spectrum Health Medical Group, USA
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Ricci C, Casadei R, Taffurelli G, Toscano F, Pacilio CA, Bogoni S, D'Ambra M, Pagano N, Di Marco MC, Minni F. Laparoscopic versus open distal pancreatectomy for ductal adenocarcinoma: a systematic review and meta-analysis. J Gastrointest Surg 2015; 19:770-81. [PMID: 25560180 DOI: 10.1007/s11605-014-2721-z] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 12/02/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Laparoscopic distal pancreatectomy was proposed as an oncologically safe approach for pancreatic ductal adenocarcinoma. METHODS A systematic review of the studies comparing laparoscopic and open distal pancreatectomy was conducted. The primary endpoint was an R0 resection rate. The secondary endpoints were intra- and postoperative results, tumour size, mean harvested lymph node, number of patients eligible for adjuvant therapy and overall survival. RESULTS Five comparative case control studies involving 261 patients (30.7% laparoscopic and 69.3% open) who underwent a distal pancreatectomy were included. The R0 resection rate was similar between the two groups (P = 0.53). The laparoscopic group had longer operative times (P = 0.04), lesser blood loss (P = 0.01), a shorter hospital stay (P < 0.001) and smaller tumour size (P = 0.04) as compared with the laparotomic group. Overall morbidity, postoperative pancreatic fistula, reoperation, mortality and number of patients eligible for adjuvant therapy were similar. The mean harvested lymph nodes were comparable in the two groups (P = 0.33). The laparoscopic approach did not affect the overall survival rate (P = 0.32). CONCLUSION Even if the number of patients compared is underpowered, the laparoscopic approach in the treatment of PDAC seems to be safe and efficacious. However, additional prospective, randomised, multicentric trials are needed to correctly evaluate the laparoscopic approach in PDAC.
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Affiliation(s)
- Claudio Ricci
- Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), Chirurgia Generale-Minni, Alma Mater Studiorum-Università di Bologna, Policlinico S.Orsola-Malpighi Via Massarenti n, 9 40138, Bologna, Italy,
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Datta J, Lewis RS, Strasberg SM, Hall BL, Allendorf JD, Beane JD, Behrman SW, Callery MP, Christein JD, Drebin JA, Epelboym I, He J, Pitt HA, Winslow E, Wolfgang C, Lee MK, Vollmer CM. Quantifying the burden of complications following total pancreatectomy using the postoperative morbidity index: a multi-institutional perspective. J Gastrointest Surg 2015; 19:506-15. [PMID: 25451733 DOI: 10.1007/s11605-014-2706-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 11/13/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND While contemporary studies demonstrate decreasing complication rates following total pancreatectomy (TP), none have quantified the impact of post-TP complications. The Postoperative Morbidity Index (PMI)-a quantitative measure of postoperative morbidity-combines ACS-NSQIP complication data with severity weighting derived from Modified Accordion Grading System. We establish the PMI for TP in a multi-institutional cohort. METHODS Nine institutions contributed ACS-NSQIP data for 64 TPs (2005-2011). Each complication was assigned an Accordion severity weight ranging from 0.110 (grade 1/mild) to 1.00 (grade 6/death). PMI equals the sum of complication severity weights ("Total Burden") divided by total number of patients. RESULTS Overall, 29 patients (45.3 %) suffered 55 ACS-NSQIP complications; 15 (23.4 %) had >1 complication. Thirteen patients (20.3 %) were readmitted and one death (1.6 %) occurred within 30 days. Non-risk adjusted PMI was 0.151, while PMI for complication-bearing cases rose to 0.333. Bleeding/Transfusion and Sepsis were the most common complications. Discordance between frequency and burden of complications was observed. While grades 4-6 comprised only 18.5 % of complications, they contributed 37.1 % to the series' total burden. CONCLUSION This multi-institutional series is the first to quantify the complication burden following TP using the rigor of ACS-NSQIP. A PMI of 0.151 indicates that, collectively, patients undergoing TP have an average burden of complications in the mild to moderate severity range, although complication-bearing patients have a considerable reduction in health utility.
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Affiliation(s)
- Jashodeep Datta
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, 19104, USA,
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Valero V, Grimm JC, Kilic A, Lewis RL, Tosoian JJ, He J, Griffin JF, Cameron JL, Weiss MJ, Vollmer CM, Wolfgang CL. A novel risk scoring system reliably predicts readmission after pancreatectomy. J Am Coll Surg 2015; 220:701-13. [PMID: 25797757 DOI: 10.1016/j.jamcollsurg.2014.12.038] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 12/17/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Postoperative readmissions have been proposed by Medicare as a quality metric and can impact provider reimbursement. Because readmission after pancreatectomy is common, we sought to identify factors associated with readmission to establish a predictive risk scoring system. STUDY DESIGN A retrospective analysis of 2,360 pancreatectomies performed at 9 high-volume pancreatic centers between 2005 and 2011 was performed. Forty-five factors strongly associated with readmission were identified. To derive and validate a risk scoring system, the population was randomly divided into 2 cohorts in a 4:1 fashion. A multivariable logistic regression model was constructed and scores were assigned based on the relative odds ratio (OR) of each independent predictor. A composite Readmission after Pancreatectomy (RAP) score was generated and then stratified to create risk groups. RESULTS Overall, 464 (19.7%) patients were readmitted within 90 days. Eight pre- and postoperative factors, including earlier MI (OR = 2.03), American Society of Anesthesiologists class ≥ 3 (OR = 1.34), dementia (OR = 6.22), hemorrhage (OR = 1.81), delayed gastric emptying (OR = 1.78), surgical site infection (OR = 3.31), sepsis (OR = 3.10), and short length of stay (OR = 1.51) were independently predictive of readmission. The 32-point RAP score generated from the derivation cohort was highly predictive of readmission in the validation cohort (area under the receiver operating curve = 0.72). The low-risk (0 to 3), intermediate-risk (4 to 7), and high-risk (>7) groups correlated with 11.7%, 17.5%, and 45.4% observed readmission rates, respectively (p < 0.001). CONCLUSIONS The RAP score is a novel and clinically useful risk scoring system for readmission after pancreatectomy. Identification of patients with increased risk of readmission using the RAP score will allow efficient resource allocation aimed to attenuate readmission rates. It also has potential to serve as a new metric for comparative research and quality assessment.
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Affiliation(s)
- Vicente Valero
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Joshua C Grimm
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Arman Kilic
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Russell L Lewis
- Department of Surgery, The University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Jeffrey J Tosoian
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jin He
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - James F Griffin
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - John L Cameron
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Matthew J Weiss
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Charles M Vollmer
- Department of Surgery, The University of Pennsylvania School of Medicine, Philadelphia, PA
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