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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. [PMID: 37667689 PMCID: PMC10475154 DOI: 10.7759/cureus.42927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2023] [Indexed: 09/06/2023] Open
Abstract
Introduction Pancreaticoduodenectomy (PD) is a complex procedure with a significant proportion of postoperative complications and improving but notable mortality. PD was the prototype procedure that initiated the lingering debate about the relationship of better operative outcomes when performed at higher-volume centers. This has not translated into practice. Impediments include the absence of a universally accepted definition of a high-volume center among others. Contrary evidence suggests equivalent outcomes for PD at low-volume centers when performed by experienced hepatobiliary surgeons. We reviewed our perioperative outcomes for PD from an earlier period as a low-volume center with an experienced team. Methods A longitudinal study of all PDs completed in our department between 2012 and 2017 was performed. Results A total of 28 PD were performed during this period. Pylorus-preserving PD was performed in 23 patients and classical PD in the remaining. A separate Roux-en-Y loop was used for high-risk pancreatic anastomosis in six cases. The mean patient age was 49.3±12.4 years. The male-to-female ratio was 1.3:1. Preoperative drainage procedures were carried out in 19 patients. The mean serum total bilirubin level was 3.98(±4.5) mg/dL. There was no 90-day mortality. Postoperative complications included wound infection in 10 (36.7%) and respiratory complications in 10 (36.7%) patients. Postoperative bleeding requiring intervention occurred in one patient, and two patients had an anastomotic leak (one pancreatojejunostomy (PJ) and one gastrojejunostomy (GJ)). Delayed gastric emptying (DGE) was noted in three (10.7%) patients. The mean length of hospital stay was 14±7 days. The median overall survival (OS) was 84 months. Conclusion Comparable early outcomes can be achieved at low-volume centers for patients undergoing PD with an experienced team, optimal patient selection, and the ability to rescue for complications.
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Affiliation(s)
- Muhammad A Khan
- Hepato-Pancreato-Biliary (HPB) Surgery, Sindh Institute of Urology and Transplantation, Karachi, PAK
- General Surgery, Sindh Institute of Medical Sciences, Karachi, PAK
- Transplant Surgery, Sindh Institute of Urology and Transplantation, Karachi, PAK
| | - Shah Muhammad
- Hepato-Pancreato-Biliary (HPB) Surgery, Sindh Institute of Urology and Transplantation, Karachi, PAK
- General Surgery, Sindh Institute of Medical Sciences, Karachi, PAK
- Transplant Surgery, Sindh Institute of Urology and Transplantation, Karachi, PAK
| | - Haider Mehdi
- Transplant Surgery, Sindh Institute of Urology and Transplantation, Karachi, PAK
- General Surgery, Sindh Institute of Medical Sciences, Karachi, PAK
| | - Abida Parveen
- Hepato-Pancreato-Biliary (HPB) Surgery, Sindh Institute of Urology and Transplantation, Karachi, PAK
- General Surgery, Sindh Institute of Medical Sciences, Karachi, PAK
| | - Uzma Soomro
- Hepato-Pancreato-Biliary (HPB) Surgery, Sindh Institute of Urology and Transplantation, Karachi, PAK
- General Surgery, Sindh Institute of Medical Sciences, Karachi, PAK
| | | | - Abdaal W Khan
- Hepato-Pancreato-Biliary (HPB) Surgery, Sindh Institute of Urology and Transplantation, Karachi, PAK
- General Surgery, Sindh Institute of Medical Sciences, Karachi, PAK
- Transplant Surgery, Sindh Institute of Urology and Transplantation, Karachi, PAK
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Purkayastha J, Bannoth S, Talukdar A, Borthakur BB, Kalita D, Das G, Kamalasanan K. Postoperative pancreatic fistulas after pancreaticoduodenectomy for malignancy: A Northeast Indian tertiary cancer center study. JGH OPEN 2021; 5:1009-1014. [PMID: 34584968 PMCID: PMC8454483 DOI: 10.1002/jgh3.12609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 06/22/2021] [Accepted: 06/25/2021] [Indexed: 12/04/2022]
Abstract
Background and Aim Postoperative pancreatic fistula (POPF) is an important cause of major morbidity and mortality after pancreaticoduodenectomy. We intend to estimate the incidence and study the risk factors and outcomes of patients who developed this dreaded complication. Methods This is a retrospective observational study. We included all patients who underwent pancreaticoduodenectomy at a specialized surgical unit of a single tertiary care cancer center in Northeast India. The period of study was from 23 April 2012 to 27 December 2019. The 2016 update on the definition of POPF by the International Study Group for Pancreatic Fistula was used to define the complication. Chi‐square test and Fischer's exact test were applied to categorical variables. t‐test was used to quantify mean difference among continuous variables. P value <0.05 was considered statistically significant at 95% confidence interval. Results A total of 59 patients underwent pancreaticoduodenectomy during the study period with almost equal distribution among males and females (29 and 30 patients respectively). The mean age of the patients was 54.0 years (range 20–72). Grade A, B, and C pancreatic fistulas were seen in five (8.5%), three (5.1%), and two (3.4%) patients, respectively. Preoperative hyperbilirubinemia, pancreatic duct size ≤3 mm, hypoalbuminemia, preoperative biliary decompression, and prolonged duration of surgery were identified as risk factors for POPF. POPF also resulted in increased 90‐day mortality (20%). Conclusion POPF remains a potentially life‐threatening complication of pancreaticoduodenectomies. The knowledge and management of modifiable risk factors for this condition may help in mitigating this problem.
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Affiliation(s)
- Joydeep Purkayastha
- Department of surgical oncology Dr. B. Borooah Cancer Institute Guwahati India
| | - Srinivas Bannoth
- Department of surgical oncology Dr. B. Borooah Cancer Institute Guwahati India
| | - Abhijit Talukdar
- Department of surgical oncology Dr. B. Borooah Cancer Institute Guwahati India
| | | | - Deepjyoti Kalita
- Department of surgical oncology Dr. B. Borooah Cancer Institute Guwahati India
| | - Gaurav Das
- Department of surgical oncology Dr. B. Borooah Cancer Institute Guwahati India
| | - Kiran Kamalasanan
- Department of surgical oncology Dr. B. Borooah Cancer Institute Guwahati India
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Twelve Hundred Consecutive Pancreato-Duodenectomies from Single Centre: Impact of Centre of Excellence on Pancreatic Cancer Surgery Across India. World J Surg 2021; 44:2784-2793. [PMID: 31641837 DOI: 10.1007/s00268-019-05235-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Pancreato-duodenectomy (PD) is a technically challenging operation with significant morbidity and mortality. Over the period of time, Tata Memorial Centre has evolved into a high-volume centre for management of pancreatic cancer. Aim of this study is to report the short- and long-term outcomes of 1200 consecutive PDs performed at single tertiary cancer centre in India. METHODS 1200 PDs were performed from 1992 to 2017. Prospectively maintained database was used to retrospectively assess the short- and long-term outcomes. RESULTS Study cohort was divided into periods A and B (500 and 700 patients, respectively). Both groups were comparable for demographic variables. Overall morbidity and mortality in entire cohort were 31.2% and 3.9%, respectively. Period B documented significant reduction in post-operative mortality (5.4% vs 2.8%), post-pancreatectomy haemorrhage (5.8% vs 3%) and bile leaks (3.4% vs 1.3%). However, incidence of delayed gastric emptying and clinically relevant post-operative pancreatic fistula was higher in period B. With median follow-up of 25 months, 3-year overall survival and disease-free survival for patients with pancreatic cancer were 43.7% and 38.7%, respectively, and that for periampullary tumours were 65.9% and 59.4%, respectively. Period B also corresponded with dissemination of technical expertise across diverse regions of India with specialised training of 35 surgeons. CONCLUSION Our study demonstrates the feasibility of delivering high-quality care in a dedicated high-volume centre even in a country with low incidence of pancreatic cancer with marked disparities in medical care and socio-economic conditions. Improved outcomes underscore the need to promote regionalisation via a dedicated training programme.
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Shinde RS, Pandrowala S, Navalgund S, Pai E, Bhandare MS, Chaudhari VA, Sullivan R, Shrikhande SV. Centralisation of Pancreatoduodenectomy in India: Where Do We Stand? World J Surg 2021; 44:2367-2376. [PMID: 32161986 DOI: 10.1007/s00268-020-05466-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The volume-outcome relationship dictates that high-volume centres lead to improved patient outcomes after pancreatoduodenectomy (PD). We conducted a retrospective review to fathom the situation in India for PD and whether referral to high-volume centres would make a positive impact. METHOD A systematic literature search in MEDLINE was performed, and all articles published from Indian centres from 01.03.2008 to 30.11.2019 were scrutinised. Any series with less than 20 patients, case reports, abstracts, unpublished data and personal communications were excluded. RESULTS A total of 36 unique series including 6226 patients from 24 institutes across India were identified. Amongst the 24 institutes, 2 institutes reported less than 10 cases/year, 11 reported 10-25 cases/year and 11 reported ≥26 cases/year. Overall perioperative morbidity was 42.4%, 43.4% and 41% for centres doing <10, 10-25 and ≥26 cases/year, respectively. Operative mortality also improved with increasing number of cases/year (5.1% vs. 6.6% vs. 3.2%, respectively). CONCLUSION With increasing volume of cases per year, trend towards improved PD outcomes is observed. To optimise the use of healthcare facilities, it would be pragmatic to consider building an organised referral system for complex surgeries to deliver unsurpassed patient care with maximum utilisation of the available healthcare infrastructure.
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Affiliation(s)
- Rajesh S Shinde
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Division of Cancer Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, 400012, India
| | - Saneya Pandrowala
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Division of Cancer Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, 400012, India
| | - Sunil Navalgund
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Division of Cancer Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, 400012, India
| | - Esha Pai
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Division of Cancer Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, 400012, India
| | - Manish S Bhandare
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Division of Cancer Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, 400012, India
| | - Vikram A Chaudhari
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Division of Cancer Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, 400012, India
| | - Richard Sullivan
- Institute of Cancer Policy, King's College London, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Shailesh V Shrikhande
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Division of Cancer Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, 400012, India.
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Martins T, Amante LN, Vicente C, Sousa GMD, Caurio EP, Guanilo MEE, Girondi JBR. Nursing interventions to reduce surgical site infection in potentially contaminated surgeries: an integrative review. ESTIMA 2020. [DOI: 10.30886/estima.v18.848_in] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective: Identify nursing interventions that contribute to the reduction of surgical site infections in potentially contaminated surgeries. Methods: Integrative review, carried out in four databases. There were 5,888 articles published in the period from January 2008 to July 2018, in English, Portuguese and Spanish, from which nine articles were selected after final analysis. Results: The nursing interventions appeared according to the perioperative periods: preoperative (55.55%), intraoperative (33.33%), postoperative (66.66%), being associated with: antibiotic therapy, trichotomy, alcoholic chlorhexidine bathing, hand hygiene, sterile glove/wear/ package change for fascia and skin closure, degermination, antisepsis, surgical classification, surgical time, care with dressings and drains, temperature and blood glucose control, patient education, discharge and post-hospital discharge orientation. Conclusions: Nursing interventions were identified in each perioperative period, proving to be essential for the qualification of nursing care and effective in reducing surgical site infection in potentially contaminated surgeries.
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Affiliation(s)
- Tatiana Martins
- Universidade Federal de Santa Catarina – Programa de Pós-Graduação em Enfermagem – Florianópolis (SC), Brazil
| | - Lúcia Nazareth Amante
- Universidade Federal de Santa Catarina – Programa de Pós-Graduação em Gestão do Cuidado em Enfermagem – Modalidade Profissional – Florianópolis (SC), Brazil
| | - Camila Vicente
- Universidade Federal de Santa Catarina – Residência Multiprofissional Integrada em Saúde – Florianópolis (SC), Brazil
| | | | | | | | - Juliana Balbinot Reis Girondi
- Universidade Federal de Santa Catarina – Programa de Pós-Graduação em Gestão do Cuidado em Enfermagem – Modalidade Profissional – Florianópolis (SC), Brazil
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Martins T, Amante LN, Vicente C, Sousa GMD, Caurio EP, Guanilo MEE, Girondi JBR. Intervenções de enfermagem para reduzir infecção do sítio cirúrgico em cirurgias potencialmente contaminadas: revisão integrativa. ESTIMA 2020. [DOI: 10.30886/estima.v18.848_pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objetivo: Identificar as intervenções de enfermagem que contribuem para a redução das infecções de sítio cirúrgico (ISCs) em cirurgias potencialmente contaminadas. Métodos: Revisão integrativa, realizada em quatro bases de dados. Foram encontrados 5.888 artigospublicados no período de janeiro de 2008 a julho de 2018, nos idiomas inglês, português e espanhol, sendo selecionados nove artigos após análise final. Resultados: As intervenções de enfermagem apareceram conforme os períodos perioperatórios: pré-operatório (55,55%), intraoperatório (33,33%) e pós-operatório (66,66%), estando associadas à: antibioticoterapia, tricotomia, banho de clorexidina alcoólica, higiene das mãos, troca de luva estéril/vestimenta/pacote para fechamento da fáscia e da pele, degermação, antissepsia, classificação cirúrgica, tempo cirúrgico, cuidados com curativos e drenos, controle de temperatura e glicemia, educação do paciente, orientações na alta e pós-alta hospitalar. Conclusões: As intervenções de enfermagem foram identificadas em cada período do perioperatório, mostrando-se essenciais para a qualificação da assistência de enfermagem e eficazes na redução da infecção do sítio cirúrgicos em cirurgias potencialmente contaminadas.
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Affiliation(s)
- Tatiana Martins
- Universidade Federal de Santa Catarina – Programa de Pós-Graduação em Enfermagem – Florianópolis (SC), Brazil
| | - Lúcia Nazareth Amante
- Universidade Federal de Santa Catarina – Programa de Pós-Graduação em Gestão do Cuidado em Enfermagem – Modalidade Profissional – Florianópolis (SC), Brazil
| | - Camila Vicente
- Universidade Federal de Santa Catarina – Residência Multiprofissional Integrada em Saúde – Florianópolis (SC), Brazil
| | | | | | | | - Juliana Balbinot Reis Girondi
- Universidade Federal de Santa Catarina – Programa de Pós-Graduação em Gestão do Cuidado em Enfermagem – Modalidade Profissional – Florianópolis (SC), Brazil
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