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Villodre C, Del Río-Martín J, Blanco-Fernández G, Cantalejo-Díaz M, Pardo F, Carbonell S, Muñoz-Forner E, Carabias A, Manuel-Vazquez A, Hernández-Rivera PJ, Jaén-Torrejimeno I, Kälviäinen-Mejia HK, Rotellar F, Garcés-Albir M, Latorre R, Longoria-Dubocq T, De Armas-Conde N, Serrablo A, Esteban Gordillo S, Sabater L, Serradilla-Martín M, Ramia JM. Textbook outcome in distal pancreatectomy: A multicenter study. Surgery 2024; 175:1134-1139. [PMID: 38071134 DOI: 10.1016/j.surg.2023.11.012] [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: 04/12/2023] [Revised: 11/01/2023] [Accepted: 11/11/2023] [Indexed: 03/17/2024]
Abstract
BACKGROUND Textbook outcome is an interesting quality metrics tool. Information on textbook outcomes in distal pancreatectomy is very scarce. In this study we determined textbook outcome in a distal pancreatectomy multicenter database and propose a specific definition of textbook outcome-distal pancreatectomy that includes pancreatic fistula. METHODS Retrospective multicenter observational study of distal pancreatectomy performed at 8 hepatopancreatobiliary surgery units from January 1, 2008, to December 31, 2018. The inclusion criteria were any scheduled distal pancreatectomy performed for any diagnosis and age > 18 years. Specific textbook outcome-distal pancreatectomy was defined as hospital stay P < 75, no Clavien-Dindo complications (≥ III), no hospital mortality, and no readmission recorded at 90 days, and the absence of pancreatic fistula (B/C). RESULTS Of the 450 patients included, 262 (58.2%) obtained textbook outcomes. Prolonged stay was the parameter most frequently associated with failure to achieve textbook outcomes. The textbook outcome group presented the following results. Preoperative: lower American Society of Anesthesiologists score < III, a lower percentage of smokers, and less frequent tumor invasion of neighboring organs or vascular invasion; operative: major laparoscopic approach, and less resection of neighboring organs and less operative transfusion; postoperative: lower percentage of delayed gastric emptying and pancreatic fistula B/C, and diagnosis other an adenocarcinoma. In the multivariate study, the American Society of Anesthesiologists score > II, resection of neighboring organs, B/C pancreatic fistula, and delayed gastric emptying were associated with failure to achieve textbook outcomes. CONCLUSION The textbook outcome rate in our 450 pancreaticoduodenectomies was 58.2%. In the multivariate analysis, the causes of failure to achieve textbook outcomes were American Society of Anesthesiologists score > II, resection of neighboring organs, pancreatic fistula B/C, and delayed gastric emptying. We believe that pancreatic fistula should be added to the specific definition of textbook outcome-distal pancreatectomy because it is the most frequent complication of this procedure.
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Affiliation(s)
- Celia Villodre
- Department of Surgery, Hospital General Universitario Dr. Balmis, Alicante, Spain; ISABIAL: Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, Spain; Universidad Miguel Hernández, Alicante, Spain
| | | | | | | | - Fernando Pardo
- Department of Surgery, Clínica Universidad de Navarra, Pamplona, Spain
| | - Silvia Carbonell
- Department of Surgery, Hospital General Universitario Dr. Balmis, Alicante, Spain; ISABIAL: Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, Spain
| | - Elena Muñoz-Forner
- Department of Surgery, Hospital Clínico Univertario, University of Valencia, Biomedical Research Institute, Valencia, Spain
| | | | | | | | | | | | - Fernando Rotellar
- Department of Surgery, Clínica Universidad de Navarra, Pamplona, Spain
| | - Marina Garcés-Albir
- Department of Surgery, Hospital Clínico Univertario, University of Valencia, Biomedical Research Institute, Valencia, Spain
| | - Raquel Latorre
- Hospital Universitario de Guadalajara, Guadalajara, Spain
| | | | | | - Alejandro Serrablo
- Department of Surgery, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | - Luis Sabater
- Department of Surgery, Hospital Clínico Univertario, University of Valencia, Biomedical Research Institute, Valencia, Spain
| | - Mario Serradilla-Martín
- Instituto de Investigación Sanitaria Aragón, Department of Surgery, Hospital Universitario Miguel Servet, Zaragoza, Spain.
| | - José M Ramia
- Department of Surgery, Hospital General Universitario Dr. Balmis, Alicante, Spain; ISABIAL: Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, Spain; Universidad Miguel Hernández, Alicante, Spain
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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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Abreu AA, Meier J, Alterio RE, Farah E, Bhat A, Wang SC, Porembka MR, Mansour JC, Yopp AC, Zeh HJ, Polanco PM. Association of race, demographic and socioeconomic factors with failure to rescue after hepato-pancreato-biliary surgery in the United States. HPB (Oxford) 2024; 26:212-223. [PMID: 37863740 DOI: 10.1016/j.hpb.2023.10.001] [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: 05/29/2023] [Revised: 08/12/2023] [Accepted: 10/01/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND We aimed to describe the association of patient-related factors such as race, socioeconomic status, and insurance on failure to rescue (FTR) after hepato-pancreato-biliary (HPB) surgeries. METHODS Using the National Inpatient Sample, we analyzed 98,788 elective HPB surgeries between 2004 and 2017. Major and minor complications were identified using ICD9/10 codes. We evaluated mortality rates and FTR (inpatient mortality after major complications). We used multivariate logistic regression analysis to assess racial, socioeconomic, and demographic factors on FTR, adjusting for covariates. RESULTS Overall, 43 % of patients (n = 42,256) had pancreatic operations, 36% (n = 35,526) had liver surgery, and 21% (n = 21,006) had biliary interventions. The overall major complication rate was 21% (n = 20,640), of which 8% (n = 1655) suffered FTR. Factors independently associated with increased risk for FTR were male sex, older age, higher Charlson Comorbidity Index, Hispanic ethnicity, Asian or other race, lower income quartile, Medicare insurance, and southern region hospitals. CONCLUSIONS Medicare insurance, male gender, Hispanic ethnicity, and lower income quartile were associated with increased risk for FTR. Efforts should be made to improve the identification and subsequent treatment of complications for those at high risk of FTR.
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Affiliation(s)
- Andres A Abreu
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jennie Meier
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Rodrigo E Alterio
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Emile Farah
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Archana Bhat
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Sam C Wang
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Matthew R Porembka
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - John C Mansour
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Adam C Yopp
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Herbert J Zeh
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Patricio M Polanco
- Division of Surgical Oncology, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Vawter K, Kuhn S, Pitt H, Wells A, Jensen HK, Mavros MN. Complications and failure-to-rescue after pancreatectomy and hospital participation in the targeted American College of Surgeons National Surgical Quality Improvement Program registry. Surgery 2023; 174:1235-1240. [PMID: 37612210 PMCID: PMC10592020 DOI: 10.1016/j.surg.2023.07.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 07/16/2023] [Accepted: 07/18/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND More than 700 hospitals participate in the American College of Surgeons National Surgical Quality Improvement Program, but most pancreatectomies are performed in 165 centers participating in the pancreas procedure-targeted registry. We hypothesized that these hospitals ("targeted hospitals") might provide more specialized care than those not participating ("standard hospitals"). METHODS The 2014 to 2019 pancreas-targeted and standard American College of Surgeons National Surgical Quality Improvement Program registry were reviewed regarding patient demographics, comorbidities, and perioperative outcomes using standard univariate and multivariable logistic regression analyses. Primary outcomes included 30-day mortality and serious morbidity. RESULTS The registry included 30,357 pancreatoduodenectomies (80% in targeted hospitals) and 14,800 distal pancreatectomies (76% in targeted hospitals). Preoperative and intraoperative characteristics of patients treated at targeted versus standard hospitals were comparable. On multivariable analysis, pancreatoduodenectomies performed at targeted hospitals were associated with a 39% decrease in 30-day mortality (odds ratio, 0.61; 95% confidence interval, 0.50-0.75), 17% decrease in serious morbidity (odds ratio, 0.83; 95% confidence interval, 0.77-0.89), and 41% decrease in failure-to-rescue (odds ratio, 0.59; 95% confidence interval, 0.47-0.74). These differences did not apply to distal pancreatectomies. Participation in the targeted registry was associated with higher rates of optimal surgery for both pancreatoduodenectomy (odds ratio, 1.33; 95% confidence interval, 1.25-1.41) and distal pancreatectomy (odds ratio, 1.17; 95% confidence interval, 1.06-1.30). CONCLUSION Mortality and failure-to-rescue rates after pancreatoduodenectomy in targeted hospitals were nearly half of rates in standard American College of Surgeons National Surgical Quality Improvement Program hospitals. Further research should delineate factors underlying this effect and highlight opportunities for improvement.
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Affiliation(s)
- Kate Vawter
- Department of Surgery, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Savana Kuhn
- Department of Surgery, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Henry Pitt
- Department of Surgery, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Allison Wells
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Hanna K Jensen
- Department of Surgery, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR; Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Michail N Mavros
- Department of Surgery, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR; Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR.
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Sindayigaya R, Barat M, Tzedakis S, Dautry R, Dohan A, Belle A, Coriat R, Soyer P, Fuks D, Marchese U. Modified Appleby procedure for locally advanced pancreatic carcinoma: A primer for the radiologist. Diagn Interv Imaging 2023; 104:455-464. [PMID: 37301694 DOI: 10.1016/j.diii.2023.05.008] [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: 05/31/2023] [Accepted: 05/31/2023] [Indexed: 06/12/2023]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is the most prevalent pancreatic neoplasm accounting for more than 90% of pancreatic malignancies. Surgical resection with adequate lymphadenectomy remains the only available curative strategy for patients with PDAC. Despite improvements in both chemotherapy regimen and surgical care, body/neck PDAC still conveys a poor prognosis because of the vicinity of major vascular structures, including celiac trunk, which favors insidious disease spread at the time of diagnosis. Body/neck PDAC involving the celiac trunk is considered locally advanced PDAC in most guidelines and therefore not eligible for upfront resection. However, a more aggressive surgical approach (i.e., distal pancreatectomy with splenectomy and en-bloc celiac trunk resection [DP-CAR]) was recently proposed to offer hope for cure in selected patients with locally advanced body/neck PDAC responsive to induction therapy at the cost of higher morbidity. The so-called "modified Appleby procedure" is highly demanding and requires optimal preoperative staging as well as appropriate patient preparation for surgery (i.e., preoperative arterial embolization). Herein, we review current evidence regarding DP-CAR indications and outcomes as well as the critical role of diagnostic and interventional radiology in patient preparation before DP-CAR, and early identification and management of DP-CAR complications.
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Affiliation(s)
- Rémy Sindayigaya
- Department of Digestive, Pancreatic, Hepato-biliary and Endocrine Surgery, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014, Paris, France; Université Paris Cité, Faculté de Médecine, 75006 Paris, France.
| | - Maxime Barat
- Université Paris Cité, Faculté de Médecine, 75006 Paris, France; Department of Radiology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France
| | - Stylianos Tzedakis
- Department of Digestive, Pancreatic, Hepato-biliary and Endocrine Surgery, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014, Paris, France; Université Paris Cité, Faculté de Médecine, 75006 Paris, France
| | - Raphael Dautry
- Department of Radiology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France
| | - Anthony Dohan
- Université Paris Cité, Faculté de Médecine, 75006 Paris, France; Department of Radiology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France
| | - Arthur Belle
- Department of Gastroenterology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France
| | - Romain Coriat
- Université Paris Cité, Faculté de Médecine, 75006 Paris, France; Department of Gastroenterology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France
| | - Philippe Soyer
- Université Paris Cité, Faculté de Médecine, 75006 Paris, France; Department of Radiology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014 Paris, France
| | - David Fuks
- Department of Digestive, Pancreatic, Hepato-biliary and Endocrine Surgery, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014, Paris, France; Université Paris Cité, Faculté de Médecine, 75006 Paris, France
| | - Ugo Marchese
- Department of Digestive, Pancreatic, Hepato-biliary and Endocrine Surgery, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 75014, Paris, France; Université Paris Cité, Faculté de Médecine, 75006 Paris, France
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Marchese U, Fuks D, Truant S, El Amrani M. Comment on: Failure to rescue in patients with distal pancreatectomy: a nationwide analysis of 10,632 patients. Hepatobiliary Surg Nutr 2021; 10:229-231. [PMID: 33898563 DOI: 10.21037/hbsn-21-105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Ugo Marchese
- Department of Digestive, Hepatobiliary and Endocrine Surgery, Paris University, Cochin Hospital, AP-HP, 75014 Paris, France
| | - David Fuks
- Department of Digestive, Hepatobiliary and Endocrine Surgery, Paris University, Cochin Hospital, AP-HP, 75014 Paris, France
| | - Stephanie Truant
- Department of Digestive Surgery and Transplantation, Lille University, CHRU de Lille, Lille, France
| | - Mehdi El Amrani
- Department of Digestive Surgery and Transplantation, Lille University, CHRU de Lille, Lille, France
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