Published online Mar 27, 2024. doi: 10.4240/wjgs.v16.i3.681
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
Processing time: 106 Days and 18 Hours
Pancreaticoduodenectomy (PD) is a technically complex operation, with a re
To document the rate of rescue from post-PD complications with tailored protocols in place as a measure of quality.
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. Stan
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 aggre
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, cul
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.
- Citation: Cawich SO, Dixon E, Shukla PJ, Shrikhande SV, Deshpande RR, Mohammed F, Pearce NW, Francis W, Johnson S, Bujhawan J. Rescue from complications after pancreaticoduodenectomies at a low-volume Caribbean center: Value of tailored peri-pancreatectomy protocols. World J Gastrointest Surg 2024; 16(3): 681-688
- URL: https://www.wjgnet.com/1948-9366/full/v16/i3/681.htm
- DOI: https://dx.doi.org/10.4240/wjgs.v16.i3.681
Pancreaticoduodenectomy (PD) remains the best therapeutic option for peri-ampullary malignancies[1,2]. As it is a technically complex operation, PDs should be performed by experienced teams who are facile with the operative steps and management of complications when they occur. The ability to rescue patients from succumbing to post-PD complications is recognized as a quality measure in modern practice[3-7].
Our facility in the Caribbean is a tertiary referral center where experienced pancreatic surgeons perform PD at low volumes. The primary aim of this study was to evaluate rescue rates after PD and to document short-term outcomes using tailored peri-pancreatic protocols.
We secured ethics approval to collect data for this study from a pancreatic surgery unit in the Eastern Caribbean. A dedicated unit was established on January 1, 2013, staffed by pancreatic surgeons, anesthetists, and support staff.
In this study, we carried out an audit to identify all consecutive patients who underwent PD at this facility over one decade, from January 1, 2013 to June 30, 2023. Patients were identified from operating room registers. Then hospital records were retrieved to identify patients who experienced a major complication after PD. The following data were collected from these records: patient demographics, operative details, postoperative complications, and 30-d mortality.
The criteria to be eligible for inclusion were: Age > 18 years, PD during the specified study period, availability of hospital records, and documentation of a major complication. Patients were excluded if they underwent left-sided or total pancreatic resections, had missing or incomplete records, were transferred to other facilities for any reason, and ex
We used standardized definitions from the International Study Group of Pancreatic Surgery[8,9] to define post-PD complications and the definition of pancreatic fistula proposed by the International Study Group on Pancreatic Fistula criteria[10,11]. The modified Clavien-Dindo classification[12] was used to classify post PD complications. Complications were further divided into medical and procedure-related complications using standardized classifications[13,14]. Pro
Rescue was defined as the proportion of patients who were salvaged after a major (Claviden-Dindo ≥ 3a) post-PD complication was treated[3]. Descriptive statistics were generated using SPSS version 16.0. The χ2 and t-tests were used to compare rescue rates based on patient sex, patient age (≤ 55 years vs > 55 years), type of complication (medical vs procedure-related), Eastern Cooperative Oncology Group performance scores (ECOG 0-1 vs 2-4), and physical status using the American Society of Anesthesiologists’ risk score (ASA 1-2 vs 3-5). P < 0.05 was considered statistically significant.
Over the study period, 113 patients underwent PDs at this facility. There were 71 males and 62 females at a mean age of 57.5 years (standard deviation [SD] ± 9.23; range: 30-90; median: 56). Major complications were recorded in 33 (29.2%) patients after PD. In the subgroup with major complications, there were 23 males and 10 females at a mean age of 53.8 years (SD: ± 7.9; range: 30-70; median: 53). Table 1 outlines the individual complications.
Overall morbidity | 52 (46%) |
Minor morbidity | 19 (16.8%) |
Pneumonia | 3 |
Deep vein thrombosis | 3 |
Delayed gastric emptying - grade A | 2 |
Post-pancreatectomy hemorrhage - grade A | 4 |
Superficial surgical site infection | 5 |
Bile leaks - grade A | 2 |
Major morbidity | 33 (29.2%) |
Major medical complications | |
Renal failure | 1 |
Respiratory complications | 1 |
Cardiac complications | 3 |
Systemic sepsis | 2 |
Major procedure-related complications | |
Delayed gastric emptying - grade B/C | 3 |
Bile leak - grade B/C | 5 |
Organ space collection | 2 |
Anastomotic dehiscence | 1 |
Post-operative pancreatic fistula | 10 |
Post-pancreatectomy hemorrhage - grade B/C | 5 |
30-d mortality | 4 (3.5%) |
Twenty-nine patients who experienced major morbidity were salvaged after aggressive treatment of their com
Four (3.5%) patients died as a direct consequence of their complications, resulting in an FTR rate of 12.1%. The complications from which patients could not be rescued included: Post-pancreatectomy hemorrhage from a bleeding pseudoaneurysm, septic shock secondary to a bile leak, intra-abdominal collections from an anastomotic leak, and a cardiac insufficiency due to myocardial infarction.
There were seven major medical complications and six (85.6%) were rescued after treatment of the complication. There were 26 patients with procedure-related complications and 23 (88.5%) of these patients were rescued. There was no statistically significant difference in salvage rates for medical vs procedure-related complications (P = 0.0391).
We found that salvage rates were slightly higher in patients with age ≤ 55 years (89.5% vs 83.3%; P = 0.743) and ECOG scores ≤ 1 (91.3% vs 80%; P = 0.361), female sex (90% vs 87%; P = 0.951), although neither achieved statistical significance. Due to the retrospective nature of data collection, we could not evaluate the relationship between salvage rates and body mass index (BMI). However, there was a significantly greater salvage rate in patients with ASA scores ≤ 2 (93.3% vs 25%; P = 0.0024).
Rescue from salvageable complications requires early recognition and treatment of complications. Since PD is recognized to be a technically challenging procedure with high inherent complication rates[1-4], isolated analyses of morbidity and mortality are not the best quality measures[3,6,7]. Instead, interhospital variations in mortality bear a closer relationship to the rates of rescue or failure thereof[3-7].
At our center, PD was accompanied by 29.2% major morbidity and 3.5% mortality, which is on par with reports in the surgical literature[3,13-18]. More importantly, we were able to rescue 89% of patients from major complications. The failure rate (12.1%) was at the upper limit of that reported from high-volume centers, ranging from 5.4%[8] to 12.5%[19]. This means there may still be room for improvement in complication management at our center.
Prior data suggest that rescue rates are directly proportional to hospital case volume[3,6,7,20,21]. Although there is no consensus on what constitutes a high-volume center, most authors consider high-volume hospitals as those performing > 18 PDs annually[22-26]. van Rijssen et al[3] suggested that hospital volume > 40 per year was an an independent predictor of rescue. Therefore, with an annual volume of 11.3 PDs per year, our hospital does not qualify as high volume.
We found that the only factor that predicted rescue was the patients’ physical status using the ASA risk score, in agreement with published data[3,27,28]. The surgical literature suggests that other factors predicting failure to rescue include patient-related factors, such as male sex[3], increasing age[3,27], high BMI[3], and co-morbidities[6,28,29]. Hos
Our results suggest that rescue is not necessarily related to case volumes alone. It is a much more complex issue that requires a multidisciplinary team approach, appropriate hospital equipment, and diligence on the part of the care team. In our setting where a new pancreatic service was being formed, we appreciated that a surgeon-led drive was necessary to ensure that the facility focused on recognized factors contributing to good outcomes, such as quaternary training for hepato-pancreato-biliary teams[31], trained nursing teams[32], development of care pathways[32], multidisciplinary ap
Pre-operative | Multidisciplinary care | All patients presented at a weekly multidisciplinary team meeting to review images and consensus decision making |
Patient consultation | Patient evaluated by attending surgeon to relay multidisciplinary team decisions | |
Pre-operative counseling | Verbal information during pre-operative consultation | |
Ensure patient receives a written pamphlets with information | ||
Patient education | Refer to AHPBA Caribbean Chapter video resources | |
Part one of informed consent process as outpatient | ||
Medical clearance | Pre-operative cardiopulmonary exercise testing | |
Evaluation and clearance from cardiology/pulmonology teams | ||
Pre-operative consultations with anesthesia team in patients with borderline fitness as a condition for acceptance for surgery | ||
Prehabilitation | Patients encouraged to discontinue smoking | |
Discuss exercise regime pre-operatively | ||
Pre-operative chest physiotherapy | ||
Supervised exercise regime with physical trainer | ||
Fasting guidelines | Discourage prolonged fasting | |
Encourage a carbohydrate-rich drink on the morning of surgery | ||
Biliary decompression | Appropriate decompression, as decided by multidisciplinary team | |
Ensure standard blood tests are available within 48 h of surgery | ||
Supportive care | Ensure ICU bed is reserved prior to surgery | |
Ensure ≥ 2 units of packed cells are available in the operating room | ||
Intra-operative | Pre-operative anesthesia | Avoid routine sedatives prior to surgery |
Regional block and/or rectal sheath blocks prior to surgery | ||
Surgical team | Two experienced HPB surgeons operate together | |
Dedicated nursing team | ||
Dedicated anesthetic team | ||
Prevention of intra-operative hypothermia | Close monitoring to maintain normothermia | |
Active warming devices | ||
Pneumatic compression device available | ||
Peri-operative fluid management | Patients receive intra-operative restricted goal directed fluid therapy | |
Ensure warmed fluids | ||
Specialized equipment | Ensure specialty equipment is available: Omni-Tract®, staplers | |
Peri-operative tasks | Administer thrombo-prophylaxis at induction | |
Administer prophylactic antibiotics at induction | ||
Place central line, urinary catheter, arterial lines prior to surgery | ||
Post-operative | Escalation | Follow rescue protocols and inform attending surgeon if there is any deviation from expected post-operative course |
Ambulation | Patients encouraged to ambulate on the same day post-operatively | |
Post-operative review | Surgical team rostered to physically review patient on 4 hourly shifts for 1st 36 h | |
Fluid balance | Ensure adequate urine output of 0.5-1 mL/kg/h | |
Ensure appropriate intravenous fluid regime is being followed | ||
Respiratory | Encourage coughing | |
Encourage use of incentive spirometer | ||
Ensure physiotherapist input | ||
Analgesia | Stepwise multimodal pain management to minimize opioid administration | |
Tubes | Consider early removal of urinary catheter | |
Consider early removal of nasogastric tubes | ||
Drain evaluation at post-operative day 3 | ||
Post-operative diet | Consider early oral fluid intake, once clinically appropriate | |
Thrombo-prophylaxis | Ensure pneumatic compression device is being used | |
Ensure prophylactic low molecular weight heparin is being administered |
We also needed to compensate for institutional deficiencies. For example, after we recognized that optimal care could not be delivered on the general wards in our setting, all our patients were admitted to the intensive care unit for the first 72 h. Post-operative surveillance was also inconsistent at our facility, so we compensated by scheduling members of the surgical team to physically review the patients on a 4-h rotation for the first 36 h post PD. This allowed early identification of complications and facilitated the early activation of rescue protocols. In this regard, we agree with van Rijssen et al[3] that failure to rescue was partly due to slow escalation of care[3], inadequate recognition and communication of patient deterioration to a senior colleague[30,34-36], lack of established protocols or support of team members[3], hierarchy[3], and understaffing[3].
It is important to recognize that the attending surgeon has less control in the post-operative period. It is the diligence of the nursing and support staff that allows complications to be recognized early, the experience of junior medical staff that allows appropriate steps to be taken and seniors to be notified, and the quality of care from the entire care team that will determine whether a patient is rescued. Team leaders/attending surgeons must recognize that they need cooperation from all categories of hospital staff and, many times, this is an exercise in diplomacy. To do this, attending surgeons must rely on charisma power (the ability to influence behavior through force of character) instead of coercive power (in
It is also important for the surgeon to be able to adapt to their working environment. For example, we understood early that our facility battled with unavailability of intensive care unit space, paucity of blood products, shortage of con
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, adaptive learning by the entire institution, culminating in the development of tailored peri-pancreatectomy protocols.
Peri-operative outcomes differ between institutions due to a variety of factors. This can affect the way individual hos
Our facility in the Caribbean is a low-volume center with numerous challenges. Tailored peri-pancreatic protocols were devised specifically to compensate for challenges at our facility. These have not been evaluated prior to this study.
The ability to rescue patients from post-PD complications is as a recognized quality measure. This study sought to do
A 10-year retrospective audit was performed to evaluate rescue rates in patients who experienced major post-PD complications. Standardized definitions from the International Study Group of Pancreatic Surgery were used to define post-PD com
There were 113 patients who underwent PDs and 33 experienced major morbidity. Twenty-nine (87.9%) patients were salvaged after aggressive treatment of their complication. There was a significantly greater salvage rate in patients with American Society of Anesthesiologists scores ≤ 2 (93.3% vs 25%; P = 0.0024).
Despite low volumes and multiple hospital challenges, we were able to achieve acceptable rescue rates after post-PD complications. We attributed this to several factors including development tailored peri-pancreatectomy protocols.
This adds to existing data that volume alone should not be used as a quality measure. It encourages further research with larger numbers since this early research shows encouraging results.
Provenance and peer review: Unsolicited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Surgery
Country/Territory of origin: Trinidad and Tobago
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P-Reviewer: Dilek ON, Turkey S-Editor: Gong ZM L-Editor: Filipodia P-Editor: Xu ZH
1. | Vawter K, Kuhn S, Pitt H, Wells A, Jensen HK, Mavros MN. Complications and failure-to-rescue after pancreatectomy and hospital participation in the targeted American College of Surgeons National Surgical Quality Improvement Program registry. Surgery. 2023;174:1235-1240. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 6] [Cited by in F6Publishing: 1] [Article Influence: 1.0] [Reference Citation Analysis (0)] |
2. | Schmidt CM, Turrini O, Parikh P, House MG, Zyromski NJ, Nakeeb A, Howard TJ, Pitt HA, Lillemoe KD. Effect of hospital volume, surgeon experience, and surgeon volume on patient outcomes after pancreaticoduodenectomy: a single-institution experience. Arch Surg. 2010;145:634-640. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 312] [Cited by in F6Publishing: 334] [Article Influence: 23.9] [Reference Citation Analysis (0)] |
3. | van Rijssen LB, Zwart MJ, van Dieren S, de Rooij T, Bonsing BA, Bosscha K, van Dam RM, van Eijck CH, Gerhards MF, Gerritsen JJ, van der Harst E, de Hingh IH, de Jong KP, Kazemier G, Klaase J, van der Kolk BM, van Laarhoven CJ, Luyer MD, Molenaar IQ, Patijn GA, Rupert CG, Scheepers JJ, van der Schelling GP, Vahrmeijer AL, Busch ORC, van Santvoort HC, Groot Koerkamp B, Besselink MG; Dutch Pancreatic Cancer Group. Variation in hospital mortality after pancreatoduodenectomy is related to failure to rescue rather than major complications: a nationwide audit. HPB (Oxford). 2018;20:759-767. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 65] [Cited by in F6Publishing: 80] [Article Influence: 13.3] [Reference Citation Analysis (0)] |
4. | Rosero EB, Romito BT, Joshi GP. Failure to rescue: A quality indicator for postoperative care. Best Pract Res Clin Anaesthesiol. 2021;35:575-589. [PubMed] [DOI] [Cited in This Article: ] [Cited by in F6Publishing: 8] [Reference Citation Analysis (0)] |
5. | Portuondo JI, Shah SR, Singh H, Massarweh NN. Failure to Rescue as a Surgical Quality Indicator: Current Concepts and Future Directions for Improving Surgical Outcomes. Anesthesiology. 2019;131:426-437. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 44] [Cited by in F6Publishing: 46] [Article Influence: 9.2] [Reference Citation Analysis (0)] |
6. | Burke JR, Downey C, Almoudaris AM. Failure to Rescue Deteriorating Patients: A Systematic Review of Root Causes and Improvement Strategies. J Patient Saf. 2022;18:e140-e155. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 58] [Cited by in F6Publishing: 78] [Article Influence: 39.0] [Reference Citation Analysis (0)] |
7. | Endo I, Watanabe J. Hospital volume, failure to rescue, and surgeon skills: What is a good indicator of a quality hospital? Ann Gastroenterol Surg. 2020;4:606-607. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 2] [Cited by in F6Publishing: 1] [Article Influence: 0.3] [Reference Citation Analysis (0)] |
8. | Wente MN, Veit JA, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Yeo CJ, Büchler MW. Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery. 2007;142:20-25. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 1411] [Cited by in F6Publishing: 1770] [Article Influence: 104.1] [Reference Citation Analysis (0)] |
9. | Wente MN, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Traverso LW, Yeo CJ, Büchler MW. Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery. 2007;142:761-768. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 1771] [Cited by in F6Publishing: 2149] [Article Influence: 126.4] [Reference Citation Analysis (0)] |
10. | Bassi C, Marchegiani G, Dervenis C, Sarr M, Abu Hilal M, Adham M, Allen P, Andersson R, Asbun HJ, Besselink MG, Conlon K, Del Chiaro M, Falconi M, Fernandez-Cruz L, Fernandez-Del Castillo C, Fingerhut A, Friess H, Gouma DJ, Hackert T, Izbicki J, Lillemoe KD, Neoptolemos JP, Olah A, Schulick R, Shrikhande SV, Takada T, Takaori K, Traverso W, Vollmer CR, Wolfgang CL, Yeo CJ, Salvia R, Buchler M; International Study Group on Pancreatic Surgery (ISGPS). The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 Years After. Surgery. 2017;161:584-591. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 2615] [Cited by in F6Publishing: 2615] [Article Influence: 373.6] [Reference Citation Analysis (35)] |
11. | Shrikhande SV, D'Souza MA. Pancreatic fistula after pancreatectomy: evolving definitions, preventive strategies and modern management. World J Gastroenterol. 2008;14:5789-5796. [PubMed] [DOI] [Cited in This Article: ] [Cited by in CrossRef: 46] [Cited by in F6Publishing: 50] [Article Influence: 3.1] [Reference Citation Analysis (0)] |
12. | Téoule P, Bartel F, Birgin E, Rückert F, Wilhelm TJ. The Clavien-Dindo Classification in Pancreatic Surgery: A Clinical and Economic Validation. J Invest Surg. 2019;32:314-320. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 14] [Cited by in F6Publishing: 11] [Article Influence: 1.8] [Reference Citation Analysis (0)] |
13. | Karim SAM, Abdulla KS, Abdulkarim QH, Rahim FH. The outcomes and complications of pancreaticoduodenectomy (Whipple procedure): Cross sectional study. Int J Surg. 2018;52:383-387. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 57] [Cited by in F6Publishing: 62] [Article Influence: 10.3] [Reference Citation Analysis (0)] |
14. | Simon R. Complications After Pancreaticoduodenectomy. Surg Clin North Am. 2021;101:865-874. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 4] [Cited by in F6Publishing: 30] [Article Influence: 10.0] [Reference Citation Analysis (0)] |
15. | Narayanan S, Martin AN, Turrentine FE, Bauer TW, Adams RB, Zaydfudim VM. Mortality after pancreaticoduodenectomy: assessing early and late causes of patient death. J Surg Res. 2018;231:304-308. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 39] [Cited by in F6Publishing: 44] [Article Influence: 7.3] [Reference Citation Analysis (0)] |
16. | Moazzam Z, Lima HA, Alaimo L, Endo Y, Ejaz A, Beane J, Dillhoff M, Cloyd J, Pawlik TM. Hepatopancreatic Surgeons Versus Pancreatic Surgeons: Does Surgical Subspecialization Impact Patient Care and Outcomes? J Gastrointest Surg. 2023;27:750-759. [PubMed] [DOI] [Cited in This Article: ] [Reference Citation Analysis (0)] |
17. | Nimptsch U, Krautz C, Weber GF, Mansky T, Grützmann R. Nationwide In-hospital Mortality Following Pancreatic Surgery in Germany is Higher than Anticipated. Ann Surg. 2016;264:1082-1090. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 138] [Cited by in F6Publishing: 148] [Article Influence: 18.5] [Reference Citation Analysis (0)] |
18. | Cannas S, Casciani F, Vollmer CM; Pancreas Fistula Study Group. Extending Quality Improvement for Pancreatoduodenectomy Within the High-Volume Setting: The Experience Factor. Ann Surg. 2023;. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 2] [Reference Citation Analysis (0)] |
19. | 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. [PubMed] [DOI] [Cited in This Article: ] [Cited by in F6Publishing: 1] [Reference Citation Analysis (0)] |
20. | Amini N, Spolverato G, Kim Y, Pawlik TM. Trends in Hospital Volume and Failure to Rescue for Pancreatic Surgery. J Gastrointest Surg. 2015;19:1581-1592. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 106] [Cited by in F6Publishing: 123] [Article Influence: 13.7] [Reference Citation Analysis (0)] |
21. | Merath K, Chen Q, Bagante F, Sun S, Akgul O, Idrees JJ, Dillhoff M, Schmidt C, Cloyd J, Pawlik TM. Variation in the cost-of-rescue among medicare patients with complications following hepatopancreatic surgery. HPB (Oxford). 2019;21:310-318. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 20] [Cited by in F6Publishing: 16] [Article Influence: 3.2] [Reference Citation Analysis (0)] |
22. | Bliss LA, Yang CJ, Chau Z, Ng SC, McFadden DW, Kent TS, Moser AJ, Callery MP, Tseng JF. Patient selection and the volume effect in pancreatic surgery: unequal benefits? HPB (Oxford). 2014;16:899-906. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 32] [Cited by in F6Publishing: 35] [Article Influence: 3.5] [Reference Citation Analysis (0)] |
23. | McPhee JT, Hill JS, Whalen GF, Zayaruzny M, Litwin DE, Sullivan ME, Anderson FA, Tseng JF. Perioperative mortality for pancreatectomy: a national perspective. Ann Surg. 2007;246:246-253. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 353] [Cited by in F6Publishing: 371] [Article Influence: 21.8] [Reference Citation Analysis (0)] |
24. | Alsfasser G, Kittner J, Eisold S, Klar E. Volume-outcome relationship in pancreatic surgery: the situation in Germany. Surgery. 2012;152:S50-S55. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 23] [Cited by in F6Publishing: 23] [Article Influence: 1.9] [Reference Citation Analysis (0)] |
25. | Meguid RA, Ahuja N, Chang DC. What constitutes a "high-volume" hospital for pancreatic resection? J Am Coll Surg. 2008;206:622.e1-622.e9. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 63] [Cited by in F6Publishing: 64] [Article Influence: 4.0] [Reference Citation Analysis (0)] |
26. | Briceno P, Hutson J, Shridhar R, Meredit K. Pancreatic Resection at High Volume Centers Improves Survival. HPB. 2017;19:131. [DOI] [Cited in This Article: ] [Cited by in Crossref: 6] [Cited by in F6Publishing: 6] [Article Influence: 0.9] [Reference Citation Analysis (0)] |
27. | Gleeson EM, Pitt HA, Mackay TM, Wellner UF, Williamsson C, Busch OR, Koerkamp BG, Keck T, van Santvoort HC, Tingstedt B, Besselink MG; Global Audits on Pancreatic Surgery Group (GAPASURG). Failure to Rescue After Pancreatoduodenectomy: A Transatlantic Analysis. Ann Surg. 2021;274:459-466. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 5] [Cited by in F6Publishing: 21] [Article Influence: 7.0] [Reference Citation Analysis (0)] |
28. | Pastrana Del Valle J, Mahvi DA, Fairweather M, Wang J, Clancy TE, Ashley SW, Urman RD, Whang EE, Gold JS. The improvement in post-operative mortality following pancreaticoduodenectomy between 2006 and 2016 is associated with an improvement in the ability to rescue patients after major morbidity, not in the rate of major morbidity. HPB (Oxford). 2021;23:434-443. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 4] [Cited by in F6Publishing: 14] [Article Influence: 4.7] [Reference Citation Analysis (0)] |
29. | Koerner AS, Thomas AS, Chabot JA, Kluger MD, Sugahara KN, Schrope BA. Associations Between Patient Characteristics and Whipple Procedure Outcomes Before and After Implementation of an Enhanced Recovery After Surgery Protocol. J Gastrointest Surg. 2023;27:1855-1866. [PubMed] [DOI] [Cited in This Article: ] [Reference Citation Analysis (0)] |
30. | Johnston MJ, Arora S, King D, Bouras G, Almoudaris AM, Davis R, Darzi A. A systematic review to identify the factors that affect failure to rescue and escalation of care in surgery. Surgery. 2015;157:752-763. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 145] [Cited by in F6Publishing: 127] [Article Influence: 14.1] [Reference Citation Analysis (0)] |
31. | Francis W, Arra A, Bonadie KO, Cawich SO. Evolution of Liver and Pancreas Surgical Sub-Specialty in the Caribbean: Caribbean Chapter of the Americans Hepatopancreatobiliary Association. J Carib Coll Surg. 2021;1:51-54. [DOI] [Cited in This Article: ] [Reference Citation Analysis (0)] |
32. | Cawich SO, Cabral R, Douglas J, Thomas DA, Mohammed FZ, Naraynsingh V, Pearce NW. Whipple's procedure for pancreatic cancer: training and the hospital environment are more important than volume alone. Surg Pract Sci. 2023;14:100211. [DOI] [Cited in This Article: ] |
33. | Cawich SO, Pearce NW, Naraynsingh V, Shukla P, Deshpande RR. Whipple's operation with a modified centralization concept: A model in low-volume Caribbean centers. World J Clin Cases. 2022;10:7620-7630. [PubMed] [DOI] [Cited in This Article: ] [Cited by in CrossRef: 1] [Cited by in F6Publishing: 3] [Article Influence: 1.5] [Reference Citation Analysis (4)] |
34. | Khan MA, Muhammad S, Mehdi H, Parveen A, Soomro U, Ali JF, Khan AW. Surgeon's Experience May Circumvent Operative Volume in Improving Early Outcomes After Pancreaticoduodenectomy. Cureus. 2023;15:e42927. [PubMed] [DOI] [Cited in This Article: ] [Reference Citation Analysis (0)] |
35. | Stevenson R, Ngai J, Gudlaugsdottir K, Mansouri D, Haslett A, Smith L, Stevenson K, Jackson A, Oliphant R; West of Scotland Virtual Journal Club. Escalation of Care in Surgery: a Systematic Risk Assessment to Prevent Avoidable Harm in Hospitalized Patients. Ann Surg. 2017;266:e27-e28. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 1] [Reference Citation Analysis (0)] |
36. | Ghaferi AA, Dimick JB. Understanding failure to rescue and improving safety culture. Ann Surg. 2015;261:839-840. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 42] [Cited by in F6Publishing: 44] [Article Influence: 4.9] [Reference Citation Analysis (0)] |
37. | Cawich SO, Johnson PB, Dan D, Naraynsingh V. Surgical leadership in the time of significant generational diversity. Surgeon. 2014;12:235-236. [PubMed] [DOI] [Cited in This Article: ] [Cited by in Crossref: 8] [Cited by in F6Publishing: 10] [Article Influence: 1.0] [Reference Citation Analysis (0)] |