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Endo Y, Noda H, Iseki M, Aizawa H, Inoue K, Maeda S, Kato T, Watanabe F, Rikiyama T. Thick mesopancreas is a novel predictor of surgical outcomes of patients who undergo pancreaticoduodenectomy. Langenbecks Arch Surg 2024; 409:181. [PMID: 38856758 DOI: 10.1007/s00423-024-03357-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 05/21/2024] [Indexed: 06/11/2024]
Abstract
PURPOSE Mesopancreas resection is a crucial but difficult procedure when performing pancreaticoduodenectomy. This study evaluated the influence of mesopancreas thickness on surgical outcomes in patients undergoing pancreaticoduodenectomy. METHODS We measured the thickness of the fat tissue on the right side of the superior mesenteric artery from the dorsal margin of the confluence of the superior mesenteric vein and portal vein to the ventral margin of the left renal vein on preoperative contrast-enhanced computed tomography and defined it as the mesopancreas thickness. We evaluated the correlation between mesopancreas thickness and intraoperative and postoperative variables in 357 patients who underwent pancreaticoduodenectomy. RESULTS Multivariate analysis revealed that a thick mesopancreas was significantly associated with a long operative time (β = 10.361; 95% confidence interval, 0.370-20.353, p = 0.042), high estimated blood loss (β = 36.038; 95% confidence interval, -27.192-99.268, p = 0.013), and a low number of resected lymph nodes (β = -1.551; 95% confidence interval, -2.662--0.439, p = 0.006). This analysis further revealed that thick mesopancreas was a significant risk factor for overall morbidity (odds ratio 2.170; 95% confidence interval 1.340-3.520, p = 0.002), major morbidity (odds ratio 2.430; 95% confidence interval 1.360-4.340, p = 0.003), and a longer hospital stay (β = 2.386; 95% confidence interval 0.299-4.474, p = 0.025). CONCLUSION A thick mesopancreas could predict a longer operation time, higher estimated blood loss, fewer resected lymph nodes, more frequent overall and major morbidities, and a longer hospital stay in patients who underwent pancreaticoduodenectomy more precisely than the body mass index.
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Affiliation(s)
- Yuhei Endo
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Hiroshi Noda
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan.
| | - Masahiro Iseki
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hidetoshi Aizawa
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Koetsu Inoue
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Shimpei Maeda
- Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takaharu Kato
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Fumiaki Watanabe
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Toshiki Rikiyama
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
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Blackburn KW, Brubaker LS, Van Buren Ii G, Feng E, Mohamed S, Ramamurthy U, Ramanathan V, Wood AL, Navarro Cagigas ME, Fisher WE. Real-Time Reporting of Complications in Hospitalized Surgical Patients by Surgical Team Members Using a Smartphone Application. Jt Comm J Qual Patient Saf 2024; 50:449-455. [PMID: 38565473 DOI: 10.1016/j.jcjq.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/08/2024] [Accepted: 02/09/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND The surgical morbidity and mortality (M&M) conference is a vital part of a resident's surgical education, but methods to collect and store M&M data are often rudimentary and unreliable. The authors propose a Health Insurance Portability and Accountability Act (HIPAA)-compliant, electronic health record (EHR)-connected application and database to report and store complication data. METHODS The app is linked to the patient's EHR, and as a result, basic data on each surgical case-including diagnosis, surgery type, and surgeon-are automatically uploaded to the app. In addition, all data are stored in a secure SQL database-with communications between the app and the database end-to-end encrypted for HIPAA compliance. The full surgical team has access to the app, democratizing complications reporting and allowing for reporting in both the inpatient and outpatient settings. This complication information can then be automatically pulled from the app with a premade presentation for the M&M conference. The data can also be accessed by a Power BI dashboard, allowing for easy quality improvement analyses. RESULTS When implemented, the app improved data collection for the M&M conference while providing a database for institutional quality improvement use. The authors also identified additional utility of the app, including ensuring appropriate revenue capture. The general appearance of the app and the dashboard can be found in the article. CONCLUSION The app developed in this project significantly improves on more common methods for M&M conference complication reporting-transforming M&M data into a valuable resource for resident education and quality improvement.
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Wang H, Shen B, Jia P, Li H, Bai X, Li Y, Xu K, Hu P, Ding L, Xu N, Xia X, Fang Y, Chen H, Zhang Y, Yue S. Guiding post-pancreaticoduodenectomy interventions for pancreatic cancer patients utilizing decision tree models. Front Oncol 2024; 14:1399297. [PMID: 38873261 PMCID: PMC11169653 DOI: 10.3389/fonc.2024.1399297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 04/29/2024] [Indexed: 06/15/2024] Open
Abstract
Background Pancreatic ductal adenocarcinoma (PDAC) is frequently diagnosed in advanced stages, necessitating pancreaticoduodenectomy (PD) as a primary therapeutic approach. However, PD surgery can engender intricate complications. Thus, understanding the factors influencing postoperative complications documented in electronic medical records and their impact on survival rates is crucial for improving overall patient outcomes. Methods A total of 749 patients were divided into two groups: 598 (79.84%) chose the RPD (Robotic pancreaticoduodenectomy) procedure and 151 (20.16%) chose the LPD (Laparoscopic pancreaticoduodenectomy) procedure. We used correlation analysis, survival analysis, and decision tree models to find the similarities and differences about postoperative complications and prognostic survival. Results Pancreatic cancer, known for its aggressiveness, often requires pancreaticoduodenectomy as an effective treatment. In predictive models, both BMI and surgery duration weigh heavily. Lower BMI correlates with longer survival, while patients with heart disease and diabetes have lower survival rates. Complications like delayed gastric emptying, pancreatic fistula, and infection are closely linked post-surgery, prompting conjectures about their causal mechanisms. Interestingly, we found no significant correlation between nasogastric tube removal timing and delayed gastric emptying, suggesting its prompt removal post-decompression. Conclusion This study aimed to explore predictive factors for postoperative complications and survival in PD patients. Effective predictive models enable early identification of high-risk individuals, allowing timely interventions. Higher BMI, heart disease, or diabetes significantly reduce survival rates in pancreatic cancer patients post-PD. Additionally, there's no significant correlation between DGE incidence and postoperative extubation time, necessitating further investigation into its interaction with pancreatic fistula and infection.
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Affiliation(s)
- Haixin Wang
- Department of Cadre Medical, The First Medical Centre, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Bo Shen
- Department of Respiratory and Critical Care Medicine, The Eighth Medical Centre, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Peiheng Jia
- Academy of Military Medical Science, Beijing, China
| | - Hao Li
- Academy of Military Medical Science, Beijing, China
| | - Xuemei Bai
- Academy of Military Medical Science, Beijing, China
| | - Yaru Li
- Academy of Military Medical Science, Beijing, China
| | - Kang Xu
- School of Software, Shandong University, Jinan, China
| | - Pengzhen Hu
- Academy of Military Medical Science, Beijing, China
- Northwestern Polytechnical University School of Life Sciences, Xi'an, China
| | - Li Ding
- Department of Cadre Medical, The First Medical Centre, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Na Xu
- Department of Cadre Medical, The First Medical Centre, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Xiaoxiao Xia
- Department of Cadre Medical, The First Medical Centre, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Yong Fang
- College of Mathematics and Systems Science, Shandong University of Science and Technology, Qingdao, China
| | - Hebing Chen
- Academy of Military Medical Science, Beijing, China
| | - Yan Zhang
- Department of Cadre Medical, The First Medical Centre, Chinese People's Liberation Army (PLA) General Hospital, Beijing, China
| | - Shutong Yue
- College of Mathematics and Systems Science, Shandong University of Science and Technology, Qingdao, China
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Bloomfield GC, Radkani P, Nigam A, Namgoong J, Chou J, Park BU, Fishbein TM, Winslow ER. Approach to postpancreatectomy care Impacts outcomes: Retrospective Validation of the PORSCH trial. Am J Surg 2024:S0002-9610(24)00273-3. [PMID: 38782685 DOI: 10.1016/j.amjsurg.2024.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 04/21/2024] [Accepted: 05/15/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND In the recent PORSCH trial, a three-part postpancreatectomy care algorithm was employed with a near 50 % reduction in mortality. We hypothesized that clinical care congruent with this protocol would correlate with better outcomes in our patients. METHODS Real-world postoperative care was compared to the pathway described by the PORSCH trial and patients were assigned into groups based on congruence with its recommendations. The primary composite outcome (PCO) consisted of 90-day mortality, organ failure, and interventions for bleeding. RESULTS Of 289 patients, care of 12 % was entirely congruent with the PORSCH algorithm. The PCO was recorded in 9 % of the PORSCH care group, 8 % of the Partial-PORSCH care group, and 19 % of the Non-PORSCH care group (p = 0.044). Adverse outcomes were highest when pancreaticoduodenectomy patients received care incongruent with the algorithm's CT imaging recommendations. CONCLUSIONS These results add external validity to the principles of clinical care underlying the PORSCH algorithm.
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Affiliation(s)
| | - Pejman Radkani
- Department of Transplant Surgery, Medstar Georgetown University Hospital, Washington, DC, USA
| | - Aradhya Nigam
- Department of Surgery, Medstar Georgetown University Hospital, Washington, DC, USA
| | - Jean Namgoong
- Georgetown University School of Medicine, Washington, DC, USA
| | - Jiling Chou
- MedStar Health Research Institute Department of Biostatistics & Biomedical Informatics, Hyattsville, MD, USA
| | - Byoung Uk Park
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Thomas M Fishbein
- Department of Transplant Surgery, Medstar Georgetown University Hospital, Washington, DC, USA
| | - Emily R Winslow
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
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Mie T, Sasaki T, Kobayashi K, Takeda T, Okamoto T, Kasuga A, Inoue Y, Takahashi Y, Saiura A, Sasahira N. Impact of preoperative self-expandable metal stent on benign hepaticojejunostomy anastomotic stricture after pancreaticoduodenectomy. DEN OPEN 2024; 4:e307. [PMID: 37900615 PMCID: PMC10612468 DOI: 10.1002/deo2.307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/06/2023] [Accepted: 10/16/2023] [Indexed: 10/31/2023]
Abstract
Objectives Hepaticojejunostomy anastomotic stricture (HJAS) is a serious adverse event of pancreaticoduodenectomy. Preoperative biliary drainage with a self-expandable metal stent (SEMS) is often performed before pancreaticoduodenectomy. The purpose of this study is to evaluate the risk factors and impact of preoperative SEMS placement on developing benign HJAS after pancreaticoduodenectomy. Methods We retrospectively analyzed consecutive patients who underwent pancreatoduodenectomy at our institution between July 2014 and June 2020. Risk factors for benign HJAS were identified using univariate and multivariate logistic regression analysis. We also compared outcomes of preoperative biliary drainage using SEMS and non-SEMS. Results Of the 626 included patients, benign HJAS occurred in 36 patients (5.8%). The median follow-up time was 36.7 months (interquartile range, 25.4-57.4 months). Multivariate logistic regression analysis revealed that lack of preoperative biliary drainage, preoperative bile duct diameter <5 mm, and former or current smoking were independent predictors of benign HJAS. In the preoperative biliary drainage group, the rate of preoperative bile duct diameter <5 mm was significantly lower in the SEMS group than in the non-SEMS group (2.0% vs. 12.8%, p = 0.04). Conclusions Preoperative biliary drainage with SEMS may be useful to maintain bile duct diameter ≥5 mm and to reduce benign HJAS as a result.
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Affiliation(s)
- Takafumi Mie
- Department of Hepato‐Biliary‐Pancreatic MedicineCancer Institute Hospital, Japanese Foundation for Cancer ResearchTokyoJapan
| | - Takashi Sasaki
- Department of Hepato‐Biliary‐Pancreatic MedicineCancer Institute Hospital, Japanese Foundation for Cancer ResearchTokyoJapan
| | - Kosuke Kobayashi
- Division of Hepatobiliary and Pancreatic SurgeryCancer Institute Hospital, Japanese Foundation for Cancer ResearchTokyoJapan
| | - Tsuyoshi Takeda
- Department of Hepato‐Biliary‐Pancreatic MedicineCancer Institute Hospital, Japanese Foundation for Cancer ResearchTokyoJapan
| | - Takeshi Okamoto
- Department of Hepato‐Biliary‐Pancreatic MedicineCancer Institute Hospital, Japanese Foundation for Cancer ResearchTokyoJapan
| | - Akiyoshi Kasuga
- Department of Hepato‐Biliary‐Pancreatic MedicineCancer Institute Hospital, Japanese Foundation for Cancer ResearchTokyoJapan
| | - Yosuke Inoue
- Division of Hepatobiliary and Pancreatic SurgeryCancer Institute Hospital, Japanese Foundation for Cancer ResearchTokyoJapan
| | - Yu Takahashi
- Division of Hepatobiliary and Pancreatic SurgeryCancer Institute Hospital, Japanese Foundation for Cancer ResearchTokyoJapan
| | - Akio Saiura
- Division of Hepatobiliary and Pancreatic SurgeryCancer Institute Hospital, Japanese Foundation for Cancer ResearchTokyoJapan
- Department of Hepatobiliary and Pancreatic SurgeryJuntendo University School of MedicineTokyoJapan
| | - Naoki Sasahira
- Department of Hepato‐Biliary‐Pancreatic MedicineCancer Institute Hospital, Japanese Foundation for Cancer ResearchTokyoJapan
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Wells CI, Bhat S, Xu W, Varghese C, Keane C, Baraza W, O'Grady G, Harmston C, Bissett IP. Variation in the definition of 'failure to rescue' from postoperative complications: a systematic review and recommendations for outcome reporting. Surgery 2024; 175:1103-1110. [PMID: 38245447 DOI: 10.1016/j.surg.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 11/14/2023] [Accepted: 12/12/2023] [Indexed: 01/22/2024]
Abstract
BACKGROUND Failure to rescue is the rate of death amongst patients with postoperative complications and has been proposed as a perioperative quality indicator. However, variation in its definition has limited comparisons between studies. We systematically reviewed all surgical literature reporting failure to rescue rates and examined variations in the definition of the 'numerator,' 'denominator,' and timing of failure to rescue measurement. METHODS Databases were searched from inception to 31 December 2022. All studies reporting postoperative failure to rescue rates as a primary or secondary outcome were included. We examined the complications included in the failure to rescue denominator, the percentage of deaths captured by the failure to rescue numerator, and the timing of measurement for complications and mortality. RESULTS A total of 359 studies, including 212,048,069 patients, were analyzed. The complications included in the failure to rescue denominator were reported in 295 studies (82%), with 131 different complications used. The median number of included complications per study was 10 (interquartile range 8-15). Studies that included a higher number of complications in the failure-to-rescue denominator reported lower failure-to-rescue rates. Death was included as a complication in the failure to rescue the denominator in 65 studies (18%). The median percentage of deaths captured by the failure to rescue calculation when deaths were not included in the denominator was 79%. Complications (52%) and mortality (40%) were mostly measured in-hospital, followed by 30-days after surgery. CONCLUSION Failure to rescue is an important concept in the study of postoperative outcomes, although its definition is highly variable and poorly reported. Researchers should be aware of the advantages and disadvantages of different approaches to defining failure to rescue.
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Affiliation(s)
- Cameron I Wells
- Department of Surgery, The University of Auckland, Auckland, New Zealand; Department of Surgery, Te Whatu Ora Te Toka Tumai, Auckland, New Zealand.
| | - Sameer Bhat
- Department of Surgery, The University of Auckland, Auckland, New Zealand; Department of Surgery, Te Whatu Ora MidCentral, Palmerston North, New Zealand
| | - William Xu
- Department of Surgery, The University of Auckland, Auckland, New Zealand; Department of Surgery, Te Whatu Ora Te Tai Tokerau, Whangārei, New Zealand
| | - Chris Varghese
- Department of Surgery, The University of Auckland, Auckland, New Zealand; Department of General Surgery, Te Whatu Ora Counties Manukau, Auckland, New Zealand
| | - Celia Keane
- Department of Surgery, The University of Auckland, Auckland, New Zealand; Department of Surgery, Te Whatu Ora Te Tai Tokerau, Whangārei, New Zealand
| | - Wal Baraza
- Department of Surgery, The University of Auckland, Auckland, New Zealand; Department of Surgery, Te Whatu Ora Te Toka Tumai, Auckland, New Zealand
| | - Greg O'Grady
- Department of Surgery, The University of Auckland, Auckland, New Zealand; Department of Surgery, Te Whatu Ora Te Toka Tumai, Auckland, New Zealand
| | - Chris Harmston
- Department of Surgery, The University of Auckland, Auckland, New Zealand; Department of Surgery, Te Whatu Ora Te Tai Tokerau, Whangārei, New Zealand
| | - Ian P Bissett
- Department of Surgery, The University of Auckland, Auckland, New Zealand; Department of Surgery, Te Whatu Ora Te Toka Tumai, Auckland, New Zealand
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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; 16:681-688. [PMID: 38577074 PMCID: PMC10989354 DOI: 10.4240/wjgs.v16.i3.681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/03/2024] [Accepted: 01/27/2024] [Indexed: 03/22/2024] Open
Abstract
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.
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Affiliation(s)
- Shamir O Cawich
- 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
| | - Fawwaz Mohammed
- Department of Surgery, University of the West Indies, St Augustine 000000, Trinidad and Tobago
| | - 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
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Ciprani D, Capretti G, Sorrentino M, Gramellini M, Famularo S, Casari E, Gavazzi F, Nappo G, Ridolfi C, Zerbi A. Clinical usefulness of routinely performed drain fluid cultures after pancreaticoduodenectomy. A new ally to predict patients' outcomes? Pancreatology 2024; 24:178-183. [PMID: 38171972 DOI: 10.1016/j.pan.2023.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 12/28/2023] [Accepted: 12/29/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Previous studies showed that bacterial contamination of surgical drains was associated with higher morbidity and mortality following pancreaticoduodenectomy (PD). However, there is still no agreement on the routine use of fluid drainage cultures in the management of patients underwent PD. Therefore, we aimed to clarify the role of surgical drain bacterial contamination in predicting patients' postoperative course. METHOD Single-centre study including patients underwent PD at Humanitas Research Hospital (2010-2021). Preoperative, intraoperative and postoperative data were collected. Routinely performed fluid drain cultures on postoperative day (POD) 5 were analyzed and compared among patients throughout the cohort. RESULTS A total of 825 patients were analyzed. Bacterial contamination of surgical drains was observed in 420 (50.9 %) patients and it was found to be associated with a higher rate of B/C grade pancreatic fistula (POPF) (P < 0.001), Clavien-Dindo≥3 (P < 0.001), 30-day mortality (P = 0.011), wound infection (P < 0.001), relaparotomies (P = 0.003) and greater length of hospital stay (LOS) (P < 0.001). Also, E. coli surgical drain contamination was demonstrated to double the risk of B/C grade POPF development (OR = 1.628, 95 % IC = 1.009-2.625, P = 0.046). Finally, preoperative biliary drainage (OR = 2.474, 95 % IC = 1.855-3.298, P < 0.001), age ≥75 years old (OR = 1.492, 95 % IC = 1.077-2.067, P = 0.016) and isolated Roux-en-Y pancreaticojejunostomy (OR = 1.639, 95 % IC = 1.229-2.188, P < 0.001) were identified as risk factors for surgical drains bacterial contamination. CONCLUSION Bacterial contamination of surgical drains predicts the development of B/C grade POPF and other major complications after PD. Therefore, we suggest the routine use of fluid drain cultures following PD.
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Affiliation(s)
- Debora Ciprani
- Pancreatic Surgery Unit, Humanitas Clinical and Research Hospital - IRCCS, Rozzano, Milan, Italy
| | - Giovanni Capretti
- Pancreatic Surgery Unit, Humanitas Clinical and Research Hospital - IRCCS, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Martina Sorrentino
- Pancreatic Surgery Unit, Humanitas Clinical and Research Hospital - IRCCS, Rozzano, Milan, Italy
| | - Marco Gramellini
- Pancreatic Surgery Unit, Humanitas Clinical and Research Hospital - IRCCS, Rozzano, Milan, Italy
| | - Simone Famularo
- Division of Hepatobiliary and General Surgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Erminia Casari
- Laboratory Medicine, Humanitas Clinical and Research Center, IRCCS, Rozzano, Milan, Italy
| | - Francesca Gavazzi
- Pancreatic Surgery Unit, Humanitas Clinical and Research Hospital - IRCCS, Rozzano, Milan, Italy
| | - Gennaro Nappo
- Pancreatic Surgery Unit, Humanitas Clinical and Research Hospital - IRCCS, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Cristina Ridolfi
- Pancreatic Surgery Unit, Humanitas Clinical and Research Hospital - IRCCS, Rozzano, Milan, Italy
| | - Alessandro Zerbi
- Pancreatic Surgery Unit, Humanitas Clinical and Research Hospital - IRCCS, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.
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Fickenscher M, Vorontsov O, Müller T, Radeleff B, Graeb C. Pancreaticobiliary Diseases with Severe Complications as a Rare Indication for Emergency Pancreaticoduodenectomy: A Single-Center Experience and Review of the Literature. J Clin Med 2023; 12:5760. [PMID: 37685827 PMCID: PMC10488344 DOI: 10.3390/jcm12175760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/22/2023] [Accepted: 09/02/2023] [Indexed: 09/10/2023] Open
Abstract
The pancreaticobiliary system is a complex and vulnerable anatomic region. Small changes can lead to severe complications. Pancreaticobiliary disorders leading to severe complications include malignancies, pancreatitis, duodenal ulcer, duodenal diverticula, vascular malformations, and iatrogenic or traumatic injuries. Different therapeutic strategies, such as conservative, interventional (e.g., embolization, stent graft applications, or biliary interventions), or surgical therapy, are available in early disease stages. Therapeutic options in patients with severe complications such as duodenal perforation, acute bleeding, or sepsis are limited. If less invasive procedures are exhausted, an emergency pancreaticoduodenectomy (EPD) can be the only option left. The aim of this study was to analyze a single-center experience of EPD performed for benign non-trauma indications and to review the literature concerning EPD. Between January 2015 and January 2022, 11 patients received EPD due to benign non-trauma indications at our institution. Data were analyzed regarding sex, age, indication, operative parameters, length of hospital stay, postoperative morbidity, and mortality. Furthermore, we performed a literature survey using the PubMed database and reviewed reported cases of EPD. Eleven EPD cases due to benign non-trauma indications were analyzed. Indications included peptic duodenal ulcer with penetration into the hepatopancreatic duct and the pancreas, duodenal ulcer with acute uncontrollable bleeding, and penetration into the pancreas, and a massive perforated duodenal diverticulum with peritonitis and sepsis. The mean operative time was 369 min, and the median length of hospital stay was 35.8 days. Postoperative complications occurred in 4 out of 11 patients (36.4%). Total 90-day postoperative mortality was 9.1% (1 patient). We reviewed 17 studies and 22 case reports revealing 269 cases of EPD. Only 20 cases of EPD performed for benign non-trauma indications are reported in the literature. EPD performed for benign non-trauma indications remains a rare event, with only 31 reported cases. The data analysis of all available cases from the literature revealed an increased postoperative mortality rate of 25.8%. If less invasive approaches are exhausted, EPD is still a life-saving procedure with acceptable results. Performed by surgeons with a high level of experience in hepatobiliary and pancreatic surgery, mortality rates below 10% can be achieved.
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Affiliation(s)
- Maximilian Fickenscher
- Department of General-, Visceral- and Thoracic Surgery, Sana Hospital Hof, 95032 Hof, Germany
| | - Oleg Vorontsov
- Department of General-, Visceral- and Thoracic Surgery, Sana Hospital Hof, 95032 Hof, Germany
| | - Thomas Müller
- Department of Gastroenterology, Sana Hospital Hof, 95032 Hof, Germany
| | - Boris Radeleff
- Department of Diagnostic and Interventional Radiology, Sana Hospital Hof, 95032 Hof, Germany
| | - Christian Graeb
- Department of General-, Visceral- and Thoracic Surgery, Sana Hospital Hof, 95032 Hof, Germany
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10
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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. [PMID: 37165160 DOI: 10.1007/s11605-023-05693-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 04/22/2023] [Indexed: 05/12/2023]
Abstract
PURPOSE The Enhanced Recovery After Surgery (ERAS) protocol is a multimodal perioperative care bundle aimed to improve pancreatic surgery outcomes. This work evaluates whether a Whipple ERAS protocol can be safely implemented at a quaternary care center. We also aimed to assess if race and socioeconomic factors are associated with disparities in outcomes in patients undergoing a Whipple ERAS protocol. METHODS A retrospective review identified demographic and clinical data for 458 patients undergoing pancreaticoduodenectomies (PDs) at a single institution from October 2017 to May 2022. Patients were split into two cohorts: pre-ERAS (treated before implementation) and ERAS (treated after). Outcomes included length of stay (LOS), 30-day readmission and mortality rates, and major complications. RESULTS There were 213 pre-ERAS PD patients, and 245 were managed with an ERAS protocol. More ERAS patients had a BMI > 30 (15.5% vs. 8.0%; p = 0.01) and received neoadjuvant chemotherapy (15.5% vs. 4.2%; p < 0.001). ERAS patients had a higher rate of major complications (57.6% vs. 37.6%; p < 0.001). Medicaid patients did not have more complications or longer LOS compared to non-Medicaid patients. On univariate analysis, race/ethnicity or gender was not significantly associated with a higher rate of major complications or prolonged LOS. CONCLUSION A Whipple ERAS protocol did not significantly change LOS, readmissions, or 30-day mortality. Rate of overall complications did not significantly change after implementation, but rate of major complications increased. These outcomes were not significantly impacted by race/ethnicity, gender, tumor staging, or insurance status.
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Affiliation(s)
- Anna S Koerner
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Avenue, New York, NY, 10032, USA.
| | - Alexander S Thomas
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Avenue, New York, NY, 10032, USA
| | - John A Chabot
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Avenue, New York, NY, 10032, USA
| | - Michael D Kluger
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Avenue, New York, NY, 10032, USA
| | - Kazuki N Sugahara
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Avenue, New York, NY, 10032, USA
| | - Beth A Schrope
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center, 161 Fort Washington Avenue, New York, NY, 10032, USA
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11
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Sakai H, Notake T, Shimizu A, Kubota K, Masuo H, Yoshizawa T, Hosoda K, Hayashi H, Yasukawa K, Soejima Y. Risk factors for postoperative cholangitis after pancreaticoduodenectomy and evaluation of internal stenting on hepaticojejunostomy: A single-center propensity score-based analysis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2023; 30:1065-1077. [PMID: 36866510 DOI: 10.1002/jhbp.1322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 02/04/2023] [Accepted: 02/28/2023] [Indexed: 03/04/2023]
Abstract
BACKGROUND/PURPOSE This retrospective study aimed to investigate the risk factors for postoperative cholangitis (POC) after pancreaticoduodenectomy (PD) and the efficacy of stenting on hepaticojejunostomy (HJ). METHODS We investigated 162 patients. Postoperative cholangitis occurring before and after discharge was defined as early-onset POC (E-POC) and late-onset POC (L-POC), respectively. Risk factors for E-POC and L-POC were identified using univariate and multivariate logistic regression analyses. Propensity score matching (PSM) between the stenting group (group S) and the non-stenting group (group NS), and subgroup analysis in patients with risk factors were performed to evaluate the efficacy of stenting on HJ in preventing POC. RESULTS Body mass index (BMI) ≥ 25 kg/m2 and preoperative non-biliary drainage (BD) were risk factors for E-POC and L-POC, respectively. PSM analysis revealed that E-POC occurrence was significantly higher in group S than in group NS (P = .045). In the preoperative non-BD group (n = 69), E-POC occurrence was significantly higher in group S than in group NS (P = .025). CONCLUSIONS BMI ≥ 25 kg/m2 and preoperative non-BD status were risk factors for E-POC and L-POC, respectively. Stenting on HJ implants did not prevent POC after PD.
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Affiliation(s)
- Hiroki Sakai
- Department of Surgery, Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Tsuyoshi Notake
- Department of Surgery, Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Akira Shimizu
- Department of Surgery, Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Koji Kubota
- Department of Surgery, Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Hitoshi Masuo
- Department of Surgery, Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Takahiro Yoshizawa
- Department of Surgery, Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Kiyotaka Hosoda
- Department of Surgery, Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Hikaru Hayashi
- Department of Surgery, Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Koya Yasukawa
- Department of Surgery, Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yuji Soejima
- Department of Surgery, Division of Gastroenterological, Hepato-Biliary-Pancreatic, Transplantation and Pediatric Surgery, Shinshu University School of Medicine, Matsumoto, Japan
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12
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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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13
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Cai Z, Yang Y, Han Y, Fu X, Mao L, Qiu Y. Clinical Validation of the Comprehensive Complication Index in a Pancreaticoduodenectomy Cohort. Eur Surg Res 2023; 64:334-341. [PMID: 37068477 DOI: 10.1159/000530634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 04/06/2023] [Indexed: 04/19/2023]
Abstract
INTRODUCTION Although the Clavien-Dindo classification (CDC) is the most widely utilized method for quantifying surgical complications, it fails to properly capture all events. To address this, the comprehensive complication index (CCI) was introduced. The purpose of this study was to compare the CCI and CDC as predictors of postoperative length of stay (PLOS) and total hospitalization costs in patients undergoing pancreaticoduodenectomy (PD). METHODS Data were collected from February 2018 to February 2021. Complications were graded on the CDC scale and the CCI was calculated for each patient. The correlations between CDC and CCI with PLOS and hospitalization costs were compared. Linear analyses were performed to identify factors associated with PLOS and costs. RESULTS 291 patients were enrolled with an average age of 61.2 years. 286 of them developed postoperative complications at CDC grade 1 (17.8%), 2 (59.9%), 3a (13.4%), 3b (4.5%), 4 (2.1%), and 5 (0.6%). Median CCI of the study cohort was 30.8. Spearman's correlation analysis showed the CDC and CCI were significantly correlated with PLOS and hospitalization costs, but the CCI showed a stronger correlation with PLOS (+0.552 day of stay for each additional CCI point; CCI: ρ = 0.663 vs. CDC: ρ = 0.581; p = 0.036). There were no significant differences in the correlations between total hospitalization costs and the CDC or CCI (CCI: ρ = 0.566 vs. CDC: ρ = 0.565; p = 0.78). CONCLUSION CCI is an accurate tool for quantifying morbidities after PD and shows a stronger correlation with PLOS compared with the CDC.
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Affiliation(s)
- Zhenghua Cai
- Department of General Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
- Medical School of Nanjing University, Nanjing, China
| | - Yifei Yang
- Department of General Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
- Medical School of Nanjing University, Nanjing, China
| | - Yuqing Han
- Department of General Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
- Medical School of Nanjing University, Nanjing, China
| | - Xu Fu
- Department of General Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Liang Mao
- Department of General Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Yudong Qiu
- Department of General Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
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14
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Hammad AY, Khachfe HH, AlMasri S, DeSilva A, Liu H, Nassour I, Lee K, Zureikat AH, Paniccia A. Impact of Extended Antibiotic Use After Pancreaticoduodenectomy for Patients with Preoperative Metallic Biliary Stenting Treated with Neoadjuvant Chemotherapy. J Gastrointest Surg 2023; 27:716-723. [PMID: 36650416 PMCID: PMC11234506 DOI: 10.1007/s11605-023-05581-4] [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: 08/30/2022] [Accepted: 12/22/2022] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Pancreaticoduodenectomy (PD) remains a complex surgical procedure with infectious complications affecting nearly 50% of patients. Patients who undergo biliary drainage with stent placement prior to neoadjuvant treatment (NAT) reportedly have higher infection rates following PD. The aim of the current study is to evaluate the differences in postoperative infectious complication rates based on the duration of post operative prophylactic antibiotics in patients with indwelling metal biliary stent who had NAT. METHODS A retrospective institutional pancreatic cancer database was queried for patients who had a metal biliary stent placed prior to NAT initiation, followed by subsequent PD between 2014 and 2021. Duration of postoperative prophylactic antibiotics was defined as short (SC: ≤ 24 h) or extended (EC: > 24 h-7 days). The primary outcome of interest was surgical site infection (SSI). RESULTS Two hundred and ninety-five (n = 295) patients were identified of which the majority (n = 205, 69.5%) received a short course of antibiotics postoperatively. Baseline characteristics were similar between the two cohorts including age, sex, BMI, and comorbidity index. EC patients received more NAT cycles (4 vs. 3, p < 0.001) and underwent an open PD more frequently (61.8% vs. 41.0%, p < 0.001). SSI occurred in 64 (21.7%) patients; SC cohort: 54, 26.3% vs. EC cohort:10, 11.1%, (p = 0.003). Additionally, the SC cohort demonstrated a higher incidence of major complications (Clavien-Dindo ≥ 3: 51 [24.9%] vs. 13 [14.4%], p = 0.045). On the logistic regression model examining factors associated with SSI, higher BMI (continuous variable) was associated with increased odds of SSI (OR: 1.05 [95%CI: 1.00, 1.10, p = 0.040), while EC was protective (OR: 0.36 [95%CI: 0.17, 0.75], p = 0.007). CONCLUSIONS These data suggest that an extended course of perioperative antibiotic correlates with reductions in SSI and major morbidity following PD in patients with a metallic biliary stent placed prior to NAT course. These results require validation in a future randomized clinical trial examining a larger cohort of patients with further emphasis on the types of perioperative antibiotics administered.
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Affiliation(s)
- Abdulrahman Y Hammad
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, UPMC Cancer Pavilion, 3550 Terrace Street, A425 Scaife Hall, Pittsburgh, PA, USA
| | - Hussein H Khachfe
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, UPMC Cancer Pavilion, 3550 Terrace Street, A425 Scaife Hall, Pittsburgh, PA, USA
| | - Samer AlMasri
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, UPMC Cancer Pavilion, 3550 Terrace Street, A425 Scaife Hall, Pittsburgh, PA, USA
| | - Annissa DeSilva
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, UPMC Cancer Pavilion, 3550 Terrace Street, A425 Scaife Hall, Pittsburgh, PA, USA
| | - Hao Liu
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, UPMC Cancer Pavilion, 3550 Terrace Street, A425 Scaife Hall, Pittsburgh, PA, USA
| | - Ibrahim Nassour
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, UPMC Cancer Pavilion, 3550 Terrace Street, A425 Scaife Hall, Pittsburgh, PA, USA
| | - Kenneth Lee
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, UPMC Cancer Pavilion, 3550 Terrace Street, A425 Scaife Hall, Pittsburgh, PA, USA
| | - Amer H Zureikat
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, UPMC Cancer Pavilion, 3550 Terrace Street, A425 Scaife Hall, Pittsburgh, PA, USA
| | - Alessandro Paniccia
- Division of GI Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, UPMC Cancer Pavilion, 3550 Terrace Street, A425 Scaife Hall, Pittsburgh, PA, USA.
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15
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Gazivoda VP, Greenbaum A, Beier MA, Davis CH, Kangas-Dick AW, Langan RC, Grandhi MS, August DA, Alexander HR, Pitt HA, Kennedy TJ. Pancreatoduodenectomy: the Metabolic Syndrome is Associated with Preventable Morbidity and Mortality. J Gastrointest Surg 2022; 26:2167-2175. [PMID: 35768718 DOI: 10.1007/s11605-022-05386-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 06/04/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Patients with metabolic syndrome (MS) may have increased perioperative morbidity and mortality. The aim of this analysis was to investigate the association of MS with mortality, serious morbidity, and pancreatectomy-specific outcomes in patients undergoing pancreatoduodenectomy (PD). METHODS Patients with MS who underwent PD were selected from the 2014-2018 ACS-NSQIP pancreatectomy-specific database. MS was defined as obesity (BMI ≥ 30 kg/m2), diabetes, and hypertension. Demographics and outcomes were compared by χ2 and Mann-Whitney tests, and adjusted odds ratios from multivariable logistic regression assessed the association between MS and primary outcomes. RESULTS Of 19,054 patients who underwent PD, 7.3% (n = 1388) had MS. On univariable analysis, patients with MS had significantly worse outcomes (p < 0.05): 30-day mortality (3% vs 1.8%), serious morbidity (26% vs 23%), re-intubation (4.9% vs 3.5%), pulmonary embolism (2.0% vs 1.1%), acute renal failure (1.5% vs 0.9%), cardiac arrest (1.9% vs 1.0%), and delayed gastric emptying (18% vs 16.5%). On multivariable analysis, 30-day mortality was significantly increased in patients with MS (aOR: 1.53, p < 0.01). CONCLUSION Metabolic syndrome is associated with increased morbidity and mortality in patients undergoing pancreatoduodenectomy. The association with mortality is a novel observation. Perioperative strategies aimed at reduction and/or mitigation of cardiac, pulmonary, thrombotic, and renal complications should be employed in this population given their increased risk.
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Affiliation(s)
- Victor P Gazivoda
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, 195 Little Albany St, New Brunswick, NJ, 08901, USA
| | - Alissa Greenbaum
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, 195 Little Albany St, New Brunswick, NJ, 08901, USA
| | - Matthew A Beier
- Rutgers Robert Wood Johnson Medical School, 125 Paterson St, New Brunswick, NJ, 08901, USA
| | - Catherine H Davis
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, 195 Little Albany St, New Brunswick, NJ, 08901, USA
| | - Aaron W Kangas-Dick
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, 195 Little Albany St, New Brunswick, NJ, 08901, USA
| | - Russell C Langan
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, 195 Little Albany St, New Brunswick, NJ, 08901, USA
| | - Miral S Grandhi
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, 195 Little Albany St, New Brunswick, NJ, 08901, USA
| | - David A August
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, 195 Little Albany St, New Brunswick, NJ, 08901, USA
| | - H Richard Alexander
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, 195 Little Albany St, New Brunswick, NJ, 08901, USA
| | - Henry A Pitt
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, 195 Little Albany St, New Brunswick, NJ, 08901, USA
| | - Timothy J Kennedy
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, 195 Little Albany St, New Brunswick, NJ, 08901, USA.
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16
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Raza SS, Nutu OA, Powell-Brett S, Carvalheiro Boteon A, Hodson J, Abradelo M, Dasari B, Isaac J, Chatzizacharias N, Marudanayagam R, Mirza DF, Roberts JK, Sutcliffe RP. Impact of an enhanced recovery after surgery protocol on short-term outcomes in elderly patients undergoing pancreaticoduodenectomy. HPB (Oxford) 2022; 24:1720-1728. [PMID: 35643908 DOI: 10.1016/j.hpb.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 04/30/2022] [Accepted: 05/06/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND To determine whether the short-term benefits associated with an enhanced recovery after surgery programme (ERAS) following pancreaticoduodenectomy (PD) vary with age. METHODS 830 consecutive patients who underwent PD between January 2009 and March 2019 were divided according to age: elderly (≥75 years) vs. non-elderly patients (<75 years). Within each age group, cohort characteristics and outcomes were compared between patients treated pre- and post-ERAS (ERAS was systematically introduced in December 2012). Univariable and multivariable analysis were then performed, to assess whether ERAS was independently associated with length of hospital stay (LOS). RESULTS Of the entire cohort, 577 of 830 patients (69.5%) were managed according to an ERAS protocol, and 170 patients (20.5%) were aged ≥75 years old. Patients treated post-ERAS were significantly more comorbid than those pre-ERAS, with a mean Charlson Comorbidity Index of 4.6 vs. 4.1 (p < 0.001) and 6.0 vs. 5.7 (p = 0.039) for the non-elderly and elderly subgroups, respectively. There were significantly fewer medical complications in non-elderly patients treated post-ERAS compared to pre-ERAS (12.4% vs. 22.4%; p = 0.002), but not in elderly patients (23.6% vs. 14.0%; p = 0.203). On multivariable analysis, ERAS was independently associated with reduced LOS in both elderly (14.8% reduction, 95% CI: 0.7-27.0%, p = 0.041) and non-elderly patients (15.6% reduction, 95% CI: 9.2-21.6%, p < 0.001), with the effect size being similar in each group. CONCLUSION ERAS protocols can be safely applied to patients undergoing pancreaticoduodenectomy irrespective of age. Implementation of an ERAS protocol was associated with a significant reduction in postoperative LOS in both elderly and non-elderly patients, despite higher comorbidity in the post-ERAS period.
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Affiliation(s)
- Syed S Raza
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Oana A Nutu
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | | | | | - James Hodson
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | | | - Bobby Dasari
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - John Isaac
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK
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17
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Abstract
Mortality after pancreatoduodenectomy has improved over time. This progress is likely related to advancements in failure to rescue (FTR-the percentage of patients who die after developing a major complication). Several factors associated with FTR include patient-specific risks, development of certain postoperative complications, surgeon-specific factors, hospital-specific factors, rescue techniques, and regional differences. Efforts should be made to explore additional factors such as the influence of safety culture in the postoperative setting. Improvement in FTR may be better explored through randomized controlled postoperative management trials. In stable patients, management of complications by interventional radiology is preferred over reoperation.
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Affiliation(s)
- Elizabeth M Gleeson
- University of Edinburgh and Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, Scotland UK.
| | - Henry A Pitt
- Rutgers Cancer Institute of New Jersey and Robert Wood Johnson University Hospital, 195 Little Albany Street, ET 834, New Brunswick, NJ 09083, USA
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18
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Pastrana Del Valle J, Mahvi DA, Fairweather M, Wang J, Clancy TE, Ashley SW, Urman RD, Whang EE, Gold JS. Associations of gender, race, and ethnicity with disparities in short-term adverse outcomes after pancreatic resection for cancer. J Surg Oncol 2021; 125:646-657. [PMID: 34786728 DOI: 10.1002/jso.26748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 10/03/2021] [Accepted: 10/25/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND Several studies have identified disparities in pancreatic cancer treatment associated with gender, race, and ethnicity. There are limited data examining disparities in short-term adverse outcomes after pancreatic resection for cancer. The aim of this study is to evaluate associations of gender, race, and ethnicity with morbidity and mortality after pancreatic resection for malignancy. METHODS The American College of Surgeons National Surgical Quality Improvement database was retrospectively reviewed. The χ2 test and Student's t-test were used for univariable analysis and hierarchical logistic regression for multivariable analysis. RESULTS Morbidity and major morbidity after pancreaticoduodenectomy are associated with male gender, Asian race, and Hispanic ethnicity, whereas 30-day mortality is associated with the male gender. Morbidity and major morbidity after distal pancreatectomy are associated with the male gender. Morbidity after pancreaticoduodenectomy is independently associated with male gender, Asian race, and Hispanic ethnicity; major morbidity is independently associated with male gender and Asian race, and mortality is independently associated with Hispanic ethnicity. CONCLUSIONS Gender, race, and ethnicity are independently associated with morbidity after pancreaticoduodenectomy for cancer; gender and race are independently associated with major morbidity; and ethnicity is independently associated with mortality. Further studies are warranted to determine the basis of these associations.
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Affiliation(s)
- Jonathan Pastrana Del Valle
- Department of Surgical Service, VA Boston Healthcare System, West Roxbury, Massachusetts, USA.,Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - David A Mahvi
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA.,Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Mark Fairweather
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA.,Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jiping Wang
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA.,Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Thomas E Clancy
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA.,Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Stanley W Ashley
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA.,Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Richard D Urman
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA.,Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Edward E Whang
- Department of Surgical Service, VA Boston Healthcare System, West Roxbury, Massachusetts, USA.,Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA.,Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jason S Gold
- Department of Surgical Service, VA Boston Healthcare System, West Roxbury, Massachusetts, USA.,Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA.,Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
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