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©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Mar 27, 2024; 16(3): 681-688
Published online Mar 27, 2024. doi: 10.4240/wjgs.v16.i3.681
Rescue from complications after pancreaticoduodenectomies at a low-volume Caribbean center: Value of tailored peri-pancreatectomy protocols
Shamir O Cawich, Elijah Dixon, Parul J Shukla, Shailesh V Shrikhande, Rahul R Deshpande, Fawwaz Mohammed, Neil W Pearce, Wesley Francis, Shaneeta Johnson, Johann Bujhawan
Shamir O Cawich, Fawwaz Mohammed, Department of Surgery, University of the West Indies, St Augustine 000000, Trinidad and Tobago
Elijah Dixon, Department of Surgery, Faculty of Medicine, University of Calgary, Calgary, Alberta T2N2T9, Canada
Parul J Shukla, Department of Surgery, Weill Cornell Medical College, New York, NY 10065, United States
Shailesh V Shrikhande, Department of Surgical Oncology, Tata Memorial Center, Homi Bhabha National University, Mumbai 400012, India
Rahul R Deshpande, Department of Surgery, Manchester Royal Infirmary, Manchester M13 9WL, United Kingdom
Neil W Pearce, University Surgical Unit, Southampton General Hospital, Southampton SO16 6YD, United Kingdom
Wesley Francis, Department of Surgery, University of the West Indies, Nassau N-1184, Bahamas
Shaneeta Johnson, Department of Surgery, Morehouse School of Medicine, Atlanta, GA 30310, United States
Johann Bujhawan, Department of Surgery, General Hospital in Port of Spain, Port of Spain 000000, Trinidad and Tobago
Author contributions: Cawich SO, Dixon E, Sukla PJ, and Shrikhande SV designed the research; Cawich SO, Mohammed F, Pearce NW, and Francis W performed the research; Deshpande R, Pearce NW, Johnson S, and Bujhawan J contributed data analytic tools; Cawich SO, Mohammed F, Deshpane R, Pearce NW, and Johnson S analyzed the data; Cawich SO, Dixon E, Sukla PJ, and Shrikhande SV wrote the paper; Cawich SO, Dixon E, Sukla PJ, Shrikhande SV, Deshpande R, Mohammed F, Pearce NW, Francis W, Johnson S, and Bujhawan J checked the manuscript for scientific accuracy.
Institutional review board statement: This study was approved by the Campus Research Ethics Committee, St. Augustine.
Informed consent statement: This was a retrospective review of written hospital records, the requirement for informed consent was waived by the local institutional review board.
Conflict-of-interest statement: The authors have no conflicts of interest to declare.
Data sharing statement: All data are stored by the corresponding author and will be released upon reasonable request.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
https://creativecommons.org/Licenses/by-nc/4.0/ Corresponding author: Shamir O Cawich, FACS, Professor, Department of Surgery, University of the West Indies, St. Augustine Campus, St Augustine 000000, Trinidad and Tobago. socawich@hotmail.com
Received: December 6, 2023
Peer-review started: December 6, 2023
First decision: December 28, 2023
Revised: January 3, 2024
Accepted: January 27, 2024
Article in press: January 27, 2024
Published online: March 27, 2024
BACKGROUND
Pancreaticoduodenectomy (PD) is a technically complex operation, with a relatively high risk for complications. The ability to rescue patients from post-PD complications is as a recognized quality measure. Tailored protocols were instituted at our low volume facility in the year 2013.
AIM
To document the rate of rescue from post-PD complications with tailored protocols in place as a measure of quality.
METHODS
A retrospective audit was performed to collect data from patients who experienced major post-PD complications at a low volume pancreatic surgery unit in Trinidad and Tobago between January 1, 2013 and June 30, 2023. Standardized definitions from the International Study Group of Pancreatic Surgery were used to define post-PD complications, and the modified Clavien-Dindo classification was used to classify post-PD complications.
RESULTS
Over the study period, 113 patients at a mean age of 57.5 years (standard deviation [SD] ± 9.23; range: 30-90; median: 56) underwent PDs at this facility. Major complications were recorded in 33 (29.2%) patients at a mean age of 53.8 years (SD: ± 7.9). Twenty-nine (87.9%) patients who experienced major morbidity were salvaged after aggressive treatment of their complication. Four (3.5%) died from bleeding pseudoaneurysm (1), septic shock secondary to a bile leak (1), anastomotic leak (1), and myocardial infarction (1). There was a significantly greater salvage rate in patients with American Society of Anesthesiologists scores ≤ 2 (93.3% vs 25%; P = 0.0024).
CONCLUSION
This paper adds to the growing body of evidence that volume alone should not be used as a marker of quality for patients requiring PD. Despite low volumes at our facility, we demonstrated that 87.9% of patients were rescued from major complications. We attributed this to several factors including development of rescue protocols, the competence of the pancreatic surgery teams and continuous, and adaptive learning by the entire institution, culminating in the development of tailored peri-pancreatectomy protocols.
Core Tip: Pancreaticoduodenectomy is a technically complex operation, with a relatively high risk for complications. Conventional teaching suggests that these operations should only be done in high-volume centers. Rescue, defined as the proportion of patients who were salvaged after treatment of a major complication, is a recognized quality measure. We have shown that acceptable rescue rates can be achieved at low volume centers once there is attention to detail and protocols tailored to the hospital environment.
