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Davis CH, Choubey AP, Langan RC, Grandhi MS, Kennedy TJ, August DA, Alexander HR, Pitt HA. Pancreatectomy for intraductal papillary mucinous neoplasm: has anything changed in North America? HPB (Oxford) 2024; 26:109-116. [PMID: 37805363 DOI: 10.1016/j.hpb.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 08/02/2023] [Accepted: 09/04/2023] [Indexed: 10/09/2023]
Abstract
BACKGROUND Multiple guidelines on the management of intraductal papillary mucinous neoplasm (IPMN) have been published over the past decade. However, practice data are lacking. This study aims to determine whether pancreatectomy procedures, IPMN pathology, or outcomes have changed. METHODS ACS-NSQIP Procedure Targeted Pancreatectomy database was queried for patients with IPMN from 2014 to 2019. Cases were stratified by pathology, tumor stage/cyst size and procedure. Pancreatectomies for IPMN by year, 30-day morbidity, and clinically relevant postoperative pancreatic fistula (CR-POPF) were quantified. Mann-Kendall trend tests were performed to assess surgical trends and associated outcomes over time. RESULTS 3912 patients underwent pancreatectomy for IPMN. 21% demonstrated malignancy and 79% were benign. Morbidity and mortality occurred in 29.7% and 1.5% of cases, respectively. Over time, no change was observed in use of pancreatectomy for IPMN (10%) or in benign/malignant pathology, or cyst size. Robotic approach increased from 9.1% to 16.5% with decreases in laparoscopic (19.5%-15.0%) and open interventions (71.5%-68.1%, p = 0.016). No change was observed over time in morbidity or mortality; however, rates of CR-POPF decreased (18.8%-13.8%, p < 0.001). CONCLUSIONS Practice patterns in treatment of IPMN have not changed significantly in North America. More patients are undergoing robotic pancreatectomy, and postoperative pancreatic fistula rates are improving.
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Affiliation(s)
- Catherine H Davis
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA; Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
| | - Ankur P Choubey
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Russell C Langan
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA; Department of Surgery, Cooperman Barnabas Medical Center, Livingston, NJ, USA
| | - Miral S Grandhi
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA; Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Timothy J Kennedy
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA; Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - David A August
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA; Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - H Richard Alexander
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA; Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Henry A Pitt
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA; Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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Pecorelli N, Mazza M, Guarneri G, Delpini R, Partelli S, Balzano G, Turi S, Meani R, Beretta L, Falconi M. Impact of care pathway adherence on recovery following distal pancreatectomy within an enhanced recovery program. HPB (Oxford) 2021; 23:1815-1823. [PMID: 33975798 DOI: 10.1016/j.hpb.2021.04.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 03/22/2021] [Accepted: 04/13/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND In bowel surgery, adherence to enhanced recovery program (ERP) has been associated with improved recovery. The objective of this study was to evaluate the impact of adherence to ERP elements on outcomes, and identify factors associated with successful recovery following distal pancreatectomy (DP). METHODS Data for 376 patients who underwent DP managed within an ERP including 16 perioperative elements were reviewed. Primary endpoint was successful recovery, a composite outcome defined as length of hospital stay≤7 days, no severe complications nor readmissions. RESULTS Patients had a mean (SD) overall adherence of 76 (14)%. Overall, 166 (44%) patients had a successful recovery. There was a positive association between overall adherence and successful recovery (OR 1.19, 95%CI 1.08-1.31 for every additional element, p = 0.001), while an inverse relationship was found with comprehensive complication index (8% reduction, 95%CI -15 to -2%, p = 0.011). Adherence to postoperative phase interventions had the greatest impact on recovery (OR 1.29, 95%CI 1.13-1.47 for every additional postoperative element; p < 0.001). At multivariable regression, early termination of IV fluids was the only ERP element associated with successful recovery (OR 2.80, 95%CI 1.73-4.54; p < 0.001). CONCLUSION Increased adherence to ERP elements was associated with successful early recovery and reduction of postoperative complication severity.
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Affiliation(s)
- Nicolò Pecorelli
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | | | - Giovanni Guarneri
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | | | - Stefano Partelli
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Gianpaolo Balzano
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Turi
- Department of Anesthesia, San Raffaele Scientific Institute, Milan, Italy
| | - Renato Meani
- Department of Anesthesia, San Raffaele Scientific Institute, Milan, Italy
| | - Luigi Beretta
- Department of Anesthesia, San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Falconi
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
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Elango M, Papalois V. Working towards an ERAS Protocol for Pancreatic Transplantation: A Narrative Review. J Clin Med 2021; 10:1418. [PMID: 33915899 PMCID: PMC8036565 DOI: 10.3390/jcm10071418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 03/24/2021] [Accepted: 03/27/2021] [Indexed: 12/11/2022] Open
Abstract
Enhanced recovery after surgery (ERAS) initially started in the early 2000s as a series of protocols to improve the perioperative care of surgical patients. They aimed to increase patient satisfaction while reducing postoperative complications and postoperative length of stay. Despite these protocols being widely adopted in many fields of surgery, they are yet to be adopted in pancreatic transplantation: a high-risk surgery with often prolonged length of postoperative stay and high rate of complications. We have analysed the literature in pancreatic and transplantation surgery to identify the necessary preoperative, intra-operative and postoperative components of an ERAS pathway in pancreas transplantation.
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Affiliation(s)
- Madhivanan Elango
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK;
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Ferencz S, Bíró Z, Vereczkei A, Kelemen D. Innovations in pancreatic anastomosis technique during pancreatoduodenectomies. Langenbecks Arch Surg 2020; 405:1039-1044. [PMID: 32737588 PMCID: PMC7541374 DOI: 10.1007/s00423-020-01942-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 07/21/2020] [Indexed: 12/22/2022]
Abstract
Purpose Pancreatic fistula following pancreatic resections is still a relevant complication. The present work shows the efforts of a single institute to decrease this problem. Methods A total of 130 patients (63 men, 67 women) with a mean age of 60 (range: 23–81) years were operated on between January 2013 and March 2020. The most frequent type of pancreatic resection was a Whipple procedure with partial antrectomy. During all operations, an innovative method was used, namely a modification of the purse-string suture pancreatojejunostomy. Moreover, an early drain removal policy was applied, based on the drain amylase level on the first and subsequent postoperative days. Results Mean postoperative hospital stay was 13 days (range: 7–75). The overall morbidity rate was 43.8%; the clinically relevant (grade B/C) pancreatic fistula (CR-POPF) rate was 6.9%. Delayed gastric emptying (DGE) was observed in 4% of the patients. The ratio of operative mortality was 0.7%; the reoperation rate was 5.3%. Based on the drain amylase level on the first postoperative day, two groups could be established. In the first one, the drain was removed early, on the fourth day in average (range: 2–6). In the other group, the drain was left in situ protractedly or reinserted later on. Conclusion A single center’s experience proves that the refinement of the technique can improve the results of pancreatic surgery.
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Affiliation(s)
- S Ferencz
- Department of Surgery, Clinical Center, Medical School, University of Pécs, Pécs, Hungary
| | - Zs Bíró
- Division of Surgery, County Hospital, Szombathely, Hungary
| | - A Vereczkei
- Department of Surgery, Clinical Center, Medical School, University of Pécs, Pécs, Hungary
| | - D Kelemen
- Department of Surgery, Clinical Center, Medical School, University of Pécs, Pécs, Hungary.
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