Is American College of Surgeons NSQIP organ space infection a surrogate for pancreatic fistula?

Piperacillin/tazobactam for surgical prophylaxis during pancreatoduodenectomy: meta-analysis

BACKGROUND

Pancreatoduodenectomy is associated with an increased incidence of surgical-site infections, often leading to a significant rise in morbidity and mortality. This trend underlines the inadequacy of traditional antibiotic prophylaxis strategies. Hence, the aim of this meta-analysis was to assess the outcomes of antimicrobial prophylaxis, comparing piperacillin/tazobactam with traditional antibiotics.

METHODS

Upon registering in PROSPERO, the international prospective register of systematic reviews (CRD42023479100), a systematic search of various databases was conducted over the interval 2000-2023. This inclusive search encompassed a wide range of study types, including prospective and retrospective cohorts and RCTs. The subsequent data analysis was carried out utilizing RevMan 5.4.

RESULTS

A total of eight studies involving 2382 patients who underwent pancreatoduodenectomy and received either piperacillin/tazobactam (1196 patients) or traditional antibiotics (1186 patients) as antibiotic prophylaxis during surgery were included in the meta-analysis. Patients in the piperacillin/tazobactam group had significantly reduced incidences of surgical-site infections (OR 0.43 (95% c.i. 0.30 to 0.62); P < 0.00001) and major surgical complications (Clavien-Dindo grade greater than or equal to III) (OR 0.61 (95% c.i. 0.45 to 0.81); P = 0.0008). Subgroup analysis of surgical-site infections highlighted significantly reduced incidences of superficial surgical-site infections (OR 0.34 (95% c.i. 0.14 to 0.84); P = 0.02) and organ/space surgical-site infections (OR 0.47 (95% c.i. 0.28 to 0.78); P = 0.004) in the piperacillin/tazobactam group. Further, the analysis demonstrated significantly lower incidences of clinically relevant postoperative pancreatic fistulas (grades B and C) (OR 0.67 (95% c.i. 0.53 to 0.83); P = 0.0003) and mortality (OR 0.51 (95% c.i. 0.28 to 0.91); P = 0.02) in the piperacillin/tazobactam group.

CONCLUSION

Piperacillin/tazobactam as antimicrobial prophylaxis significantly lowers the risk of postoperative surgical-site infections, major surgical complications (complications classified as Clavien-Dindo grade greater than or equal to III), clinically relevant postoperative pancreatic fistulas (grades B and C), and mortality, hence supporting the implementation of piperacillin/tazobactam for surgical prophylaxis in current practice.

Development and validation of a novel nomogram to predict postoperative pancreatic fistula after pancreatoduodenectomy using lasso-logistic regression: an international multi-institutional observational study

BACKGROUND

Existing prediction models for clinically relevant postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD) lack discriminatory power or are too complex. This study aimed to develop a simple nomogram that could accurately predict clinically relevant POPF after PD.

METHODS

A high-volume, multicenter cohort of patients who underwent PD from the American College of Surgeons-National Surgical Quality Improvement Program database in the United States during 2014-2017 was used as the model training cohort ( n =3609), and patients who underwent PD from the Pancreatic Center of the National Cancer Center Hospital in China during 2014-2019 were used as the external validation cohort ( n =1347). The study used lasso penalized regression to screen large-scale variables, then logistic regression was performed to screen the variables and build a model. Finally, a prediction nomogram for clinically relevant POPF was established based on the logistic model, and polynomial equations were extracted. The performance of the nomogram was evaluated by receiver operating characteristic curve, calibration curve, and decision curve analysis.

RESULTS

In the training and validation cohorts, there were 16.7% (601/3609) and 16.6% (224/1347) of patients who developed clinically relevant POPF, respectively. After screening using lasso and logistic regression, only six predictors were independently associated with clinically relevant POPF, including two preoperative indicators (weight and pancreatic duct size), one intraoperative indicator (pancreatic texture), and three postoperative indicators (deep surgical site infection, delayed gastric emptying, and pathology). The prediction of the new nomogram was accurate, with an area under the curve of 0.855 (95% CI: 0.702-0.853) in the external validation cohort, and the predictive performance was superior to three previously proposed POPF risk score models (all P <0.001, likelihood ratio test).

CONCLUSIONS

A reliable lasso-logistic method was applied to establish a novel nomogram based on six readily available indicators, achieving a sustained, dynamic, and precise POPF prediction for PD patients. With a limited number of variables and easy clinical application, this new model will enable surgeons to proactively predict, identify, and manage pancreatic fistulas to obtain better outcomes from this daunting postoperative complication.

Association Between Biliary Pathogens, Surgical Site Infection, and Pancreatic Fistula: Results of a Randomized Trial of Perioperative Antibiotic Prophylaxis in Patients Undergoing Pancreatoduodenectomy

OBJECTIVE

To establish the association between bactibilia and postoperative complications when stratified by perioperative antibiotic prophylaxis.

BACKGROUND

Patients undergoing pancreatoduodenectomy experience high rates of surgical site infection (SSI) and clinically relevant postoperative pancreatic fistula (CR-POPF). Contaminated bile is known to be associated with SSI, but the role of antibiotic prophylaxis in mitigation of infectious risks is ill-defined.

METHODS

Intraoperative bile cultures (IOBCs) were collected as an adjunct to a randomized phase 3 clinical trial comparing piperacillin-tazobactam with cefoxitin as perioperative prophylaxis in patients undergoing pancreatoduodenectomy. After compilation of IOBC data, associations between culture results, SSI, and CR-POPF were assessed using logistic regression stratified by the presence of a preoperative biliary stent.

RESULTS

Of 778 participants in the clinical trial, IOBC were available for 247 participants. Overall, 68 (27.5%) grew no organisms, 37 (15.0%) grew 1 organism, and 142 (57.5%) were polymicrobial. Organisms resistant to cefoxitin but not piperacillin-tazobactam were present in 95 patients (45.2%). The presence of cefoxitin-resistant organisms, 92.6% of which contained either Enterobacter spp. or Enterococcus spp., was associated with the development of SSI in participants treated with cefoxitin [53.5% vs 25.0%; odds ratio (OR)=3.44, 95% CI: 1.50-7.91; P =0.004] but not those treated with piperacillin-tazobactam (13.5% vs 27.0%; OR=0.42, 95% CI: 0.14-1.29; P =0.128). Similarly, cefoxitin-resistant organisms were associated with CR-POPF in participants treated with cefoxitin (24.1% vs 5.8%; OR=3.45, 95% CI: 1.22-9.74; P =0.017) but not those treated with piperacillin-tazobactam (5.4% vs 4.8%; OR=0.92, 95% CI: 0.30-2.80; P =0.888).

CONCLUSIONS

Previously observed reductions in SSI and CR-POPF in patients that received piperacillin-tazobactam antibiotic prophylaxis are potentially mediated by biliary pathogens that are cefoxitin resistant, specifically Enterobacter spp. and Enterococcus spp.

Piperacillin-Tazobactam Compared With Cefoxitin as Antimicrobial Prophylaxis for Pancreatoduodenectomy: A Randomized Clinical Trial

Importance

Despite improvements in perioperative mortality, the incidence of postoperative surgical site infection (SSI) remains high after pancreatoduodenectomy. The effect of broad-spectrum antimicrobial surgical prophylaxis in reducing SSI is poorly understood.

Objective

To define the effect of broad-spectrum perioperative antimicrobial prophylaxis on postoperative SSI incidence compared with standard care antibiotics.

Design, Setting, and Participants

Pragmatic, open-label, multicenter, randomized phase 3 clinical trial at 26 hospitals across the US and Canada. Participants were enrolled between November 2017 and August 2021, with follow-up through December 2021. Adults undergoing open pancreatoduodenectomy for any indication were eligible. Individuals were excluded if they had allergies to study medications, active infections, chronic steroid use, significant kidney dysfunction, or were pregnant or breastfeeding. Participants were block randomized in a 1:1 ratio and stratified by the presence of a preoperative biliary stent. Participants, investigators, and statisticians analyzing trial data were unblinded to treatment assignment.

Intervention

The intervention group received piperacillin-tazobactam (3.375 or 4 g intravenously) as perioperative antimicrobial prophylaxis, while the control group received cefoxitin (2 g intravenously; standard care).

Main Outcomes and Measures

The primary outcome was development of postoperative SSI within 30 days. Secondary end points included 30-day mortality, development of clinically relevant postoperative pancreatic fistula, and sepsis. All data were collected as part of the American College of Surgeons National Surgical Quality Improvement Program.

Results

The trial was terminated at an interim analysis on the basis of a predefined stopping rule. Of 778 participants (378 in the piperacillin-tazobactam group [median age, 66.8 y; 233 {61.6%} men] and 400 in the cefoxitin group [median age, 68.0 y; 223 {55.8%} men]), the percentage with SSI at 30 days was lower in the perioperative piperacillin-tazobactam vs cefoxitin group (19.8% vs 32.8%; absolute difference, -13.0% [95% CI, -19.1% to -6.9%]; P < .001). Participants treated with piperacillin-tazobactam, vs cefoxitin, had lower rates of postoperative sepsis (4.2% vs 7.5%; difference, -3.3% [95% CI, -6.6% to 0.0%]; P = .02) and clinically relevant postoperative pancreatic fistula (12.7% vs 19.0%; difference, -6.3% [95% CI, -11.4% to -1.2%]; P = .03). Mortality rates at 30 days were 1.3% (5/378) among participants treated with piperacillin-tazobactam and 2.5% (10/400) among those receiving cefoxitin (difference, -1.2% [95% CI, -3.1% to 0.7%]; P = .32).

Conclusions and Relevance

In participants undergoing open pancreatoduodenectomy, use of piperacillin-tazobactam as perioperative prophylaxis reduced postoperative SSI, pancreatic fistula, and multiple downstream sequelae of SSI. The findings support the use of piperacillin-tazobactam as standard care for open pancreatoduodenectomy.

Trial Registration

ClinicalTrials.gov Identifier: NCT03269994.

Radical antegrade modular pancreatosplenectomy (RAMPS): does adrenalectomy alter outcomes?

BACKGROUND

Radical antegrade modular pancreatosplenectomy (RAMPS) has oncologic superiority compared to a standard distal pancreatectomy (DP). For tumors invading into the adrenal gland, a posterior RAMPS takes the left adrenal gland en bloc with the pancreas specimen. The aim of this analysis is to determine whether addition of adrenalectomy alters the outcomes of DP.

METHODS

The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) Procedure-Targeted Pancreatectomy database was accessed from 2014 to 2019. Patients with pancreatic ductal adenocarcinoma (PDAC) undergoing posterior RAMPS were compared to patients having a standard DP. 30-day outcomes were analyzed using multivariable regression.

RESULTS

3467 PDAC patients underwent DP; 159 (4.6%) also had an adrenalectomy. Posterior RAMPS patients had higher T stage (T3-4 77% vs. 58%, p < 0.01). On multivariable analysis, posterior RAMPS patients had worse perioperative outcomes including more transfusions (OR 2.78, p < 0.01), serious morbidity (OR 1.45, p = 0.04), prolonged hospital stay (OR 1.36, p < 0.05), and less optimal pancreatic surgery (OR 0.61, p < 0.01).

CONCLUSION

Radical antegrade modular pancreatosplenectomy with adrenalectomy (posterior RAMPS) is associated with worse perioperative outcomes compared to a standard distal pancreatectomy. Improved oncologic outcomes must be weighed against higher perioperative morbidity when selecting patients for this more extensive surgical resection.

Failure to Rescue After the Whipple: What Do We Know?

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.

Neoadjuvant Therapy for Pancreatic Cancer: Increased Use and Improved Optimal Outcomes

BACKGROUND

The introduction of more effective chemotherapy a decade ago has led to increased use of neoadjuvant therapy (NAT) in patients with pancreatic ductal adenocarcinoma (PDAC). The aim of this study was to assess the evolving use of NAT in individuals with PDAC undergoing pancreatoduodenectomy (PD) and to compare their outcomes with patients undergoing upfront operation.

STUDY DESIGN

The American College of Surgeons NSQIP Procedure Targeted Pancreatectomy database was queried from 2014 to 2019. Patients undergoing pancreatoduodenectomy were evaluated based on the use of NAT versus upfront operation. Multivariable analysis was performed to determine the effect of NAT on postoperative outcomes, including the composite measure optimal pancreatic surgery (OPS). Mann-Kendall trend tests were performed to assess the use of NAT and associated outcomes over time.

RESULTS

A total of 13,257 patients were identified who underwent PD for PDAC between 2014 and 2019. Overall, 33.6% of patients received NAT. The use of NAT increased steadily from 24.2% in 2014 to 42.7% in 2019 (p < 0.0001). On multivariable analysis, NAT was associated with reduced serious morbidity (odds ratio [OR] 0.83, p < 0.001), clinically relevant pancreatic fistulas (OR 0.52, p < 0.001), organ space infections (OR 0.74, p < 0.001), percutaneous drainage (OR 0.73, p < 0.001), reoperation (OR 0.76, p = 0.005), and prolonged length of stay (OR 0.63, p < 0.001). OPS was achieved more frequently in patients undergoing NAT (OR 1.433, p < 0.001) and improved over time in patients receiving NAT (50.7% to 56.6%, p < 0.001).

CONCLUSION

NAT before pancreatoduodenectomy increased more than 3-fold over the past decade and was associated with improved optimal operative outcomes.

Specific Bile Microorganisms Caused by Intra-Abdominal Abscess on Pancreaticoduodenectomy Patients: A Retrospective Cohort Study

We retrospectively collected PD patients with a performance of bile culture between 2007 and 2019 in our institute. As to bile culture, we used a swab to do intraoperative bile cultures after transection of the CBD. IAA was defined as the documental bacteriological culture from either a turbid discharge from the intraoperatively placed drain in patients with a clinical picture consistent with infection or a postoperative fluid collection managed by CT-guided placement of drains. A total of 1244 PD patients were identified, and 539 (43.3%) subjects with bile sampling were included for analysis. Among these study patients, 433 (80.3%) developed bile contamination (positive bile culture). Bile contamination showed a significantly higher rate of IAA compared to non-bile contamination (17.1% vs. 0.9%, p < 0.001). The rate of co-shared microorganisms in both bile and abscess was 64.1%. On the multivariate analysis, age and specific bile microorganisms (Enterococcus species, Escherichia Coli, Streptococcus species, Citrobacter species, and Candida) are significantly associated with development of IAA. Specific bile microorganisms are the highly significant factors associated with development of IAA. The strategy to prevent bile spillage during PD should be considered to minimize afterward contamination of the abdominal cavity and prevent IAA.

Effect of wound protectors on surgical site infection in patients undergoing whipple procedure

BACKGROUND

Conflicting data persists for use of wound protectors in pancreatoduodenectomy (PD) to prevent surgical site infection (SSI). We aimed to examine, at a multi-institutional level, the effect of wound protectors on superficial or deep SSI following elective open PD.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program pancreatectomy procedure targeted participant use file was queried from 2016 to 2018. Planned open PD procedures were extracted. Univariable, multivariable, and propensity score matched analyses were conducted.

RESULTS

11,562 patients undergoing PD were evaluated, 27% of which used wound protectors. Wound protectors decreased superficial or deep SSI risk in all patients (5.7% vs. 9.5%, P < 0.001), patients who have (6.6% vs. 12.2%, P < 0.001) and who did not have (4.6% vs. 6.5%, P = 0.011) a biliary stent. Propensity score matched analysis confirms such results (OR = 0.56, 95% CI: 0.46-0.69, P < 0.001 overall, OR = 0.66, 95% CI: 0.46-0.95, P = 0.03 without biliary stent, OR = 0.57, 95% CI: 0.44-0.73, P < 0.001 with biliary stent).

CONCLUSIONS

Wound protectors reduce risk of superficial or deep SSI in patients undergoing PD, yet only a quarter of PD were associated with their use. This protective effect is seen whether patients have or have not had preoperative biliary stenting.

Geriatric nutritional risk index serves as risk factor of surgical site infection after pancreatoduodenectomy: a validation cohort Ageo study

Background

Surgical site infections (SSIs), which are associated with preoperative malnutrition, are a well-known potential complication of surgery that leads to increased medical costs and longer hospitalizations. Thus, surgeons need to accurately identify patients at high-risk for SSIs. Considering that the Geriatric Nutritional Risk Index (GNRI) was designed to assess the degree of malnutrition specifically among elderly patients, previous evidence (Kawaguchi study) proved that GNRI predicted the risk of SSIs in patients following pancreatoduodenectomy (PD). In this study, we aimed to validate whether that the same index could predict the risk of SSI among patients who underwent PD in our patient cohort (Ageo study).

Methods

The current validation cohort study was retrospectively conducted on 93 patients at the Department of Surgery, Ageo Central General Hospital, Japan, from January 2015 to October 2019. All patients were subjected to nutritional screening using the GNRI and were followed up for the occurrence of postoperative complications. Additionally, risk factors for developing SSI, as well as patient's height, body mass index, and preoperative laboratory values, were recorded.

Results

Patients were divided into the SSI (N=30) and non-SSI (N=63) groups with a determined SSI incidence rate of 32.3% (30/93). The SSI group had significantly lower GNRI than the non-SSI group (P<0.001). Receiver operating characteristic curve analysis determined a cutoff GNRI value of 94 (sensitivity, 83.3%; specificity, 83.6%), similar to that in the previous study. Univariate and multivariate analyses confirmed that a GNRI of <94 was significantly associated with SSI (P<0.001).

Conclusions

The present Ageo study confirmed the consistency of results in Kawaguchi study. Thus, lower GNRI can be a universal marker for SSI risk following PD.

Summary perioperative risk metrics within the electronic medical record predict patient-level cost variation in pancreaticoduodenectomy

BACKGROUND

Automated data extraction from the electronic medical record is fast, scalable, and inexpensive compared with manual abstraction. However, concerns regarding data quality and control for underlying patient variation when performing retrospective analyses exist. This study assesses the ability of summary electronic medical record metrics to control for patient-level variation in cost outcomes in pancreaticoduodenectomy.

METHODS

Patients that underwent pancreaticoduodenectomy from 2014 to 2018 at a single institution were identified within the electronic medical record and linked with the National Surgical Quality Improvement Program. Variables in both data sets were compared using interrater reliability. Logistic and linear regression modelling of complications and costs were performed using combinations of comorbidities/summary metrics. Models were compared using the adjusted R² and Akaike information criterion.

RESULTS

A total of 117 patients populated the final data set. A total of 31 (26.5%) patients experienced a complication identified by the National Surgical Quality Improvement Program. The median direct variable cost for the encounter was US$14,314. Agreement between variables present in the electronic medical record and the National Surgical Quality Improvement Program was excellent. Stepwise linear regression models of costs, using only electronic medical record-extractable variables, were non-inferior to those created with manually abstracted individual comorbidities (R² = 0.67 vs 0.30, Akaike information criterion 2,095 vs 2,216). Model performance statistics were minimally impacted by the addition of comorbidities to models containing electronic medical record summary metrics (R² = 0.67 vs 0.70, Akaike information criterion 2,095 vs 2,088).

CONCLUSION

Summary electronic medical record perioperative risk metrics predict patient-level cost variation as effectively as individual comorbidities in the pancreaticoduodenectomy population. Automated electronic medical record data extraction can expand the patient population available for retrospective analysis without the associated increase in human and fiscal resources that manual data abstraction requires.

Lower geriatric nutritional risk index predicts postoperative pancreatic fistula in patients with distal pancreatectomy

Postoperative pancreatic fistula (POPF) is a common complication following pancreatic resection. It leads to increased medical costs, and longer hospital stays. However, the risk factors of POPF are still unclear, and therefore, this urgent clinical issue should be resolved. The geriatric nutritional risk index (GNRI) is tool to assess the nutritional status using body weight, and serum albumin value, particularly in elderly patients. On the other hand, POPF is associated with body mass index (BMI). Thus, the present study aimed to investigate whether GNRI can predict the risk of POPF in patients after distal pancreatectomy (DP). We conducted a retrospective cohort study involving 37 patients who were treated at the Department of Digestive Surgery, Kawaguchi Municipal Medical Center between January 2007 and June 2018. All patients were subjected to nutritional screening using GNRI, and were followed up after DP for postoperative complications including POPF. In addition, risk factors of POPF, and patient's height, BMI, and preoperative laboratory values were analyzed. POPF was observed in 7 of the 37 (19%) patients. Those with a POPF had significantly lower GNRI values than those without POPF (P<0.001). Receiver operating characteristic curve analysis was performed to determine a cut-off value of GNRI, which indicated an increased risk of POPF. This value was determined as 96 (sensitivity: 71.4%, specificity: 86.7%, likelihood ratio: 5.36). Univariate analysis confirmed that a GNRI of <96 was significantly associated with POPF (P=0.005), and a multivariate logistic regression analysis revealed that a GNRI of <96 was significant independent predictor of POPF (P=0.005), suggesting its utility for assessing the risk of POPF following DP.

Biliary microbiome in pancreatic cancer: alterations with neoadjuvant therapy

BACKGROUND

Neoadjuvant therapy for pancreatic cancer is being employed more commonly. Most of these patients undergo biliary stenting which results in bacterial colonization and more surgical site infections (SSIs). However, the influence of neoadjuvant therapy on the biliary microbiome has not been studied.

METHODS

From 2007 to 2017, patients at our institution who underwent pancreatoduodenectomy (PD) and had operative bile cultures were studied. Patient demographics, stent placement, bile cultures, bacterial sensitivities, SSIs and clinically-relevant postoperative pancreatic fistulas (CR-POPF) were analyzed. Patients who underwent neoadjuvant therapy were compared to those who went directly to surgery. Standard statistical analyses were performed.

RESULTS

Eighty-three patients received neoadjuvant therapy while 89 underwent surgery alone. Patients who received neoadjuvant therapy were more likely to have enterococci (45 vs 22%, p < 0.01), and Klebsiella (37 vs 19%, p < 0.01) in their bile. Resistance to cephalosporins was more common in those who received neoadjuvant therapy (76 vs 60%, p < 0.05). Neoadjuvant therapy did not affect the incidence of SSIs or CR-POPFs.

CONCLUSION

The biliary microbiome is altered in patients undergoing pancreatoduodenectomy (PD) after neoadjuvant therapy. Most patients undergoing PD with a biliary stent have microorganisms resistant to cephalosporins. Antibiotic prophylaxis in these patients should cover enterococci and gram-negative bacteria.

Antimicrobial Stewardship Reduces Surgical Site Infection Rate, as well as Number and Severity of Pancreatic Fistulae after Pancreatoduodenectomy

Background: Surgical site infections (SSIs) remain a major source of morbidity after pancreatoduodenectomy (PD). We noted a higher than anticipated incidence of SSI in our patients undergoing PD, and after an internal audit and detailed analysis of the microflora of SSIs, as well as a multidisciplinary discussion, the local prophylactic antibiotic policy was changed based on sensitivities to the bacteria isolated from post-operative infections. The hypothesis was that a targeted change in antibiotic prophylaxis would reduce the rate of SSIs. The aim of the current study was to analyze the results of a change in prescribing policy on SSI rates, and in addition, on the occurrence and severity of post-operative pancreatic fistulae (POPF) because this complication is often linked to the presence of an organ/space SSI. Methods: After implementing a change of prophylaxis policy from cefalexin to ceftriaxone and metronidazole, and educating staff and residents, a prospectively maintained departmental database was used to identify consecutive patients undergoing PD pre- and post-institution of policy change. Incidence data relating to SSIs and POPF were obtained from the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) data set and the details of culture results and organism sensitivity extracted from the electronic medical record, as were details on the severity of fistulae, and verified by the senior author. Results: The pre- and post-implementation cohorts consisted of 111 and 216 patients, respectively, and were matched in terms of all demographic features. After the change in the antibiotic prophylaxis policy, there was a reduction in the overall SSI rate (26.4% vs. 14.8%; p = 0.01) and the organ/space SSI rate (OS-SSI; 15.3% vs. 8.6%; p = 0.03). There were also reductions in the POPF rate (38.2% vs. 19%; p = 0.002) and in the clinically relevant POPF (CR-POPF; 23.4% vs. 6.0%; p = 0.001). The rate of Clostridium difficile infections also decreased (8.1% vs.1.9%; p = 0.006) as did the median length of hospital stay (7 vs. 6 days; p = 0.003). After excluding patients with a penicillin allergy (n = 24) from the post-implementation cohort, cases compliant (158/192) and non-compliant (34/192) to the new antibiotic policy were compared. The overall SSI (26.4% vs. 10.7%; p = 0.025), OS-SSI (17.6% vs. 5.1%; p = 0.021), overall POPF (32.4 vs. 14.6; p = 0.023); CR-POPF (10.8% vs. 5.5%; p = 0.047) and Clostridium difficile (8.8% vs. 1.3%; p = 0.040) were all lower in the compliant patient cohort. Conclusions: A change in antibiotic prophylaxis prior to PD based on the local microflora, resulted in reductions in SSI, POPF, and Clostridium difficile rates.

Full Robotic Distal Pancreatectomy: Safety and Feasibility Analysis of a Multicenter Cohort of 236 Patients

Introduction. Despite the widespread use of the robotic technology, only a few studies with small sample sizes report its application to pancreatic diseases treatment. Our aim is to present the results of a multicenter study on the safety and feasibility of robot-assisted distal pancreatectomy (RDP). Materials and Methods. All RDPs for benign, borderline, and malignant diseases performed in 5 referral centers from 2008 to 2016 were included. Perioperative outcomes were evaluated. Results. Two hundred thirty-six patients were included. Spleen preservation was performed in 114 cases (48.3%). Operative time was 277.8 ± 93.6 minutes. Progressive improvement in operative time was observed over the study period. Conversion rate was 6.3%. Morbidity occurred in 102 cases (43.2%), mainly due to grade A fistulas. Reoperation was required in 10 patients. Postoperatively, 2 patients died of sepsis due to a grade C fistula. Hospital readmission was necessary in 11 cases. A R0 resection was always achieved, with a mean number of 16.2 ± 15 harvested lymph nodes. Conclusion. To our knowledge, this is one of the largest RDP series. Safety and feasibility including the low conversion rate, the high spleen preservation rate, the adequate operative time, and the acceptable morbidity and mortality rates confirm the validity of this technique. Appropriate oncological outcomes have been also obtained.

Laparoscopic spleen-preserving distal versus central pancreatectomy for tumors in the pancreatic neck and proximal body

For benign and borderline tumors in the pancreatic neck and proximal body, laparoscopic spleen-preserving distal pancreatectomy (LSPDP) and laparoscopic central pancreatectomy (LCP) are alternative surgical procedures. Choosing between LSPDP and LCP is difficult. This retrospective cohort study was looking forward to provide evidence for clinical decision.A total of 59 patients undergoing LSPDP (Kimura procedure) and LCP between June 2013 and March 2017 were selected. The clinical outcomes of patients were compared by χ test or Fisher exact test and Student t test.This study included 36 patients in LSPDP group, and 23 patients in LCP group. The overall complications incidence in LCP group was significantly higher than LSPDP group (35 vs 6%, P = .004), and the postoperative pancreatic fistula (POPF) (grade B and C) rate and abdominal infection rate in LCP group were still significantly higher than LSPDP group (POPF 22 vs 3%, P = .019; abdominal infection 35 vs 3%, P = .001, respectively). The length of resected pancreas was significantly longer in LSPDP group (9.8 ± 2.0 vs 5.3 ± 1.1 cm, P = .007). The median follow-up was 39 months (range 12-57 months). No patient was confronted by tumor recurrence. The proportion of postoperative pancreatin and insulin treatment in LCP group were similar to LSPDP group (9 vs 17%, P = .383; 0 vs 3%, P = 1.000, respectively).For patients with poor general condition, the safety of LCP needs to be taken seriously; in some ways, LSPDP may be more secure, physiological, and easier operation for tumor located in pancreatic neck and proximal body.

Patient-specific predictors of failure to rescue after pancreaticoduodenectomy

BACKGROUND

Failure to rescue (FTR) is a recently described outcome metric for quality of care. However, predictors of FTR have not been adequately investigated, particularly after pancreaticoduodenectomy. We aim to identify predictors of FTR after pancreaticoduodenectomy.

METHODS

We reviewed all patients who developed serious morbidity after pancreaticoduodenectomy from 2005 to 2012 in the ACS-NSQIP database. Logistic regression was used to identify preoperative and postoperative risks for 30-day mortality within a development cohort (randomly selected 80%). A score was created using weighted beta coefficients. Predictive accuracy was assessed on the validation cohort (remaining 20%) using a receiver operator characteristic curve and calculating the area under the curve (AUC).

RESULTS

The FTR rate was 7.2% after pancreaticoduodenectomy (n = 5,027). We identified 5 independent risk factors: age ≥65 and albumin ≤3.5 g/dL, preoperatively; and development of shock, renal failure, and reintubation, postoperatively. The generated score had an AUC = 0.83 (95% CI, 0.77-0.89) in the validation cohort. Using the score: 1*Albumin ≤3.5 g/dL + 2*Age ≥ 65 + 2*Shock + 5*Renal failure + 5*Reintubation, FTR rates increased with increasing score (p < 0.001).

CONCLUSION

FTR rates have previously been shown to be associated with hospital factors. We show that FTR is also associated with preoperative and postoperative patient-specific factors.

Wound protectors mitigate superficial surgical site infections after pancreatoduodenectomy

BACKGROUND

Whether the choice of antibiotic prophylaxis, the type of incision, or the use of wound protectors decreases surgical site infections (SSIs) in patients undergoing pancreatoduodenectomy (PD) remains unknown.

METHODS

Patients undergoing open, elective PD between January 1, 2016 and June 30, 2017 were identified from the American College of Surgeons' National Surgical Quality Improvement Program registry. Multivariable logistic regression models were constructed to determine the association of antibiotic prophylaxis type, incision type, and wound protector use on the incidence of any, superficial, and organ/space SSIs, and to profile hospitals.

RESULTS

Overall, 5969 patients were included from 140 hospitals. The overall rate of SSI was 20.3% (n = 1213). Superficial SSIs occurred in 432 (7.2%) patients and organ/space SSIs in 841 (14.1%). Wound protector use was associated with 23% lower odds of experiencing any SSIs (OR 0.77, 95% CI 0.60-0.98), reflective of the decreased odds associated with superficial SSIs (OR 0.65, 95% CI 0.44-0.97), but not organ/space SSIs (OR 0.89, 95% CI 0.68-1.17). Highest-performing hospitals frequently utilized broad-spectrum antibiotics, midline incisions, and wound protectors.

CONCLUSION

Wound protectors reduced superficial, but not organ/space, infections in patients undergoing pancreatoduodenectomy. Routine use of wound protectors in patients undergoing proximal pancreatectomy is recommended.

Preoperative hematocrit on early prosthetic joint infection and deep venous thrombosis rates in primary total hip arthroplasty: A database study

BACKGROUND

Total hip arthroplasty (THA) is a very successful surgery in restoring a patient's quality of life. Infection is a devastating complication of THA. Many risks factors for infection in THA have been identified but little is known of the effect by preoperative hematocrit.

PURPOSE

We aimed to evaluate the effect of preoperative hematocrit on early superficial site infections, deep infections, and deep organ space infections.

METHODS

Our study cohort included patients undergoing a THA in the ACS National Surgical Quality Improvement Program database from 2006 to 2015. We conducted a multivariate logistic regression analysis to evaluate an association between preoperative hematocrit and infection controlling for patients demographics and known risk factors.

RESULTS

A total of 98,869 patients were identified in this study. Of these, 702 (0.71%) developed a superficial site infection, 314 (0.32%) a deep infection, and 226 (0.23%) an organ space infection. Our results suggested a significant increased risk of deep infection (OR = 2.38, p = 0.0120) and organ space infection (OR = 3.05, p = 0.0234) in patients with lower preoperative hematocrit (<41). In addition, patients with lower preoperative hematocrit had higher chance to receive postoperative transfusion (OR = 2.93, p < 0.0001). However, no significant associations between preoperative hematocrit and superficial site infections (p = 0.8554), wound dehiscence (p = 0.0660) and DVT (p = 0.9236) were detected.

CONCLUSION

Low preoperative hematocrit is associated with increased risk of deep, organ space infections, and postoperative transfusion in THA, but not with superficial site infections, wound dehiscence and DVT.

Discrepancy in Postoperative Outcomes between Auditing Databases: A NSQIP Comparison

In 2014, ACS-NSQIP® targeted pancreatectomies to improve outcome reporting and risk calculation related to pancreatectomy. At the same time, our department began prospectively collecting data for pancreatectomy in the Enhanced Recovery After Surgery® Interactive Audit System (EIAS). The purpose of this study is to compare reported outcomes between two major auditing databases for the same patients undergoing pancreatectomy. The same 171 patients were identified in both databases. Clinical outcomes were then obtained from each database and compared to determine whether reported complication rates were statistically different between auditing databases. A combination of Wilcoxon rank sum and Pearson's chi-squared tests were used to calculate statistical significance. No significant difference was appreciated in captured demographics between EIAS and NSQIP. Significant differences in reported rates for renal dysfunction, postoperative pancreatic fistula, return to the operative room, and urinary tract infection were noted between EIAS and NSQIP. Although significant differences in reported complication rates were demonstrated between EIAS and NSQIP for pancreatectomy, much of the discrepancy is attributable to subtle differences in definitions for postoperative occurrences between the two auditing databases. It is vital for surgeons to understand the exact definition that determines the complication rate for a given database.

Geriatric nutritional risk index predicts surgical site infection after pancreaticoduodenectomy

Surgical site infections (SSIs) are a well-known potential complication of surgery. They are assocaited with preoperative malnutrition and lead to increased medical costs and longer hospital stays. Therefore, surgeons should appropriately identify patients who are at a high risk. The geriatric nutritional risk index (GNRI) is a tool, increasingly utilized to assess the degree of malnutrition, particularly in elderly patients. Therefore, the present study attempted to validate whether GNRI could predict the risk of SSI in patients following pancreaticoduodenectomy (PD). A cohort study was retrospectively conducted on 106 patients in the Department of Digestive Surgery, Kawaguchi Municipal Medical Center, Japan from January 2007 to December 2017. All patients were subjected to nutritional screening using GNRI and followed up for the occurrence of postoperative complications, including SSI post PD. Additionally, risk factors for developing SSI, and the patient's height, body mass index and preoperative laboratory values were documented. Patients were divided into SSI (n=15) and non-SSI (n=91) groups with a determined incidence of 14.2% (15/106) for SSI. The results revealed that the SSI group had GNRI values that were significantly reduced compared with the non-SSI group (P<0.001). Receiver operating characteristic curve analysis was performed to determine the cut-off value of GNRI that conferred an increased risk of SSI; it was determined as 94 (sensitivity 80.0%, specificity 83.5%). Univariate analysis confirmed that a GNRI <94 was significantly associated with SSI (P<0.001), whereas multivariate logistic regression analysis revealed that a GNRI <94 was independently associated with SSI following PD (relative risk=1.73, 95% confidence interval=1.23-2.43; P<0.001). Therefore, a GNRI <94 is a potential predictive marker for SSI risk following PD.

Impact of operative time on early joint infection and deep vein thrombosis in primary total hip arthroplasty

PURPOSE

Infections and deep vein thrombosis (DVT) after total hip arthroplasty (THA) are challenging problems for both the patient and surgeon. Previous studies have identified numerous risk factors for infections and DVT after THA but have often been limited by sample size. We aimed to evaluate the effect of operative time on early postoperative infection as well as DVT rates following THA. We hypothesized that an increase in operative time would result in increased odds of acquiring an infection as well as a DVT.

METHODS

We conducted a retrospective analysis of prospectively collected data using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2006 to 2015 for all patients undergoing primary THA. Associations between operative time and infection or DVT were evaluated with multivariable logistic regressions controlling for demographics and several known risks factors for infection. Three different types of infections were evaluated: (1) superficial surgical site infection (SSI), an infection involving the skin or subcutaneous tissue, (2) deep SSI, an infection involving the muscle or fascial layers beneath the subcutaneous tissue, and (3) organ/space infection, an infection involving any part of the anatomy manipulated during surgery other than the incisional components.

RESULTS

In total, 103,044 patients who underwent THA were included in our study. Our results suggested a significant association between superficial SSIs and operative time. Specifically, the adjusted odds of suffering a superficial SSI increased by 6% (CI=1.04-1.08, p<0.0001) for every 10-minute increase of operative time. When using dichotomized operative time (<90minutes or >90minutes), the adjusted odds of suffering a superficial SSI was 56% higher for patients with prolonged operative time (CI=1.05-2.32, p=0.0277). The adjusted odds of suffering a deep SSI increased by 7% for every 10-minute increase in operative time (CI=1.01-1.14, p=0.0335). No significant associations were detected between organ/space infection, wound dehiscence, or DVT and operative time either as continuous or as dichotomized.

CONCLUSION

Prolonged operative times (>90min) are associated with increased rates of superficial SSIs, but not deep SSIs, organ/space infections, wound dehiscence, or DVT.

LEVEL OF EVIDENCE

III.

Indication for en bloc pancreatectomy with colectomy: when is it safe?

INTRODUCTION

Aggressive en bloc resection of adjacent organs is often necessary to resect pancreatic or colonic lesions. However, it is debated whether simultaneous pancreatectomy with colectomy (P+C) is warranted as it potentially increases morbidity and mortality (MM). We hypothesized that MM would be increased in P+C, especially in cases of pancreatitis.

METHODS

All patients who underwent pancreatectomy (P) and simultaneous pancreatectomy with colectomy (P+C) at a high-volume center from November 2006 to 2015 were prospectively collected using ACS-NSQIP at our institution. Patients with additional multivisceral or enucleation procedures were excluded. Data were augmented to 90-day outcomes using our institutional database.

RESULTS

Forty-three patients with a mean age of 62 years (27:16 male: female) underwent P+C, accounting for 2.39% (43/1797) of pancreatectomies performed. Pancreatoduodenectomy (PD) was performed in 61% (n = 26), distal pancreatectomy (DP) in 37% (n = 16), and total pancreatectomy (TP) in 2% (n = 1) of patients. The 30- and 90-day MM were higher in P+C than P (30-day: 54 vs. 37%, p = 0.037 and 9 vs. 2%, p = 0.022; 90-day: 61 vs. 42%, p = 0.019 and 14 vs. 3%, p = 0.002). Logistical regression modeling revealed an association between 90-day mortality and colectomy (p = 0.013, OR = 3.556). When P+C MM were analyzed according to intraoperative factors, there was no significant difference according to type of pancreatectomy (PD vs. DP vs. TP), origin of primary lesion (pancreas vs. colon), surgical indication (malignant vs. non-malignant), or case status (planned colectomy vs. intraoperative decision).

CONCLUSIONS

Addition of colectomy to pancreatectomy substantially increased MM. Subanalysis revealed that type of resection performed, etiology, and planning status did not account for increased risk when performing P+C. However, colectomy was found to be an independent risk factor for mortality. Therefore, patients should be informed of the risk of increased postoperative complications until a further study can identify potential patients or perioperative factors that can be used for risk stratification.

Reduced morbidity with minimally invasive distal pancreatectomy for pancreatic adenocarcinoma

BACKGROUND

Minimally invasive distal pancreatectomy (MISDP) has been shown to be safe relative to open distal pancreatectomy (ODP). However, MISDP has been slow to adopt for pancreatic adenocarcinoma (PDAC). This study sought to compare outcomes following MISDP vs. ODP for PDAC.

METHODS

Data were prospectively collected from 2011 to 2014 for DP by the American College of Surgeons-National Surgical Quality Improvement Program. Patients without PDAC on surgical pathology were excluded. Impact of minimally invasive approach on morbidity and mortality was analyzed using two-way statistical analyses.

RESULTS

Of 6198 patients undergoing DP, 501 (7.5%) had a pathologic diagnosis of PDAC. MISDP was undertaken in 166 (33.1%) patients, ODP was performed in 335 (66.9%). MISDP and ODP were not different in preoperative comorbidities or pathologic stage. Overall morbidity (MISDP 31%, ODP 42%; p = 0.024), transfusion (MISDP 6%, ODP 23%; p = 0.0001), pneumonia (MISDP 1%, ODP 7%; p = 0.004), surgical site infections (MISDP 8%, OPD 17%; p = 0.013), sepsis (MISDP 2%, ODP 8%; p = 0.007), and length of stay (MISDP 5.0 days, ODP 7.0 days; p = 0.009) were lower in the MIS group. Mortality (MISDP 0%, ODP 1%; p = 0.307), pancreatic fistula (MISDP 12%, ODP 19%; p = 0.073), and delayed gastric emptying (MISDP 3%, ODP 7%; p = 0.140) were similar.

CONCLUSIONS

This analysis of a large multi-institution North American experience of DP for treatment of pancreatic adenocarcinoma suggests that short-term postoperative outcomes are improved with MISDP.

Whipple-specific complications result in prolonged length of stay not accounted for in ACS-NSQIP Surgical Risk Calculator

BACKGROUND

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Surgical Risk Calculator was developed to help counsel patients regarding estimated postoperative risk for a variety of surgical complications. This retrospective single institutional study examined the calculator's ability to accurately predict complications and length of hospital stay (LOS) in patients who had undergone a Pancreaticoduodenectomy (PD) at our institution.

METHODS

165 patients at Washington University School of Medicine who underwent a PD from 8/2011 to 7/2013 were included. Surgical complication risk as determined by the ACS-NSQIP Surgical Risk Calculator were compared to actual 30 day complications. PD complications not accounted for by the calculator were compared to those without PD-specific complications.

RESULTS

Overall predicted LOS was significantly shorter than actual duration of hospitalization (median 8.5 vs. 8.0 days; p < 0.001). 38% patients (n = 62) with Whipple-specific complication demonstrated a significant increase in LOS (8.0 vs. 12.2 days; p < 0.0001).

DISCUSSION

A large proportion of complications experienced after PD are pancreas-specific, accounting for the difference in predicted vs. actual LOS and providing rationale for future development of PD specific risk models.

Hemorrhage after pancreaticoduodenectomy: does timing matter?

BACKGROUND

Hemorrhage after pancreaticoduodenectomy is a potentially fatal complication. We retrospectively reviewed state-wide data to evaluate incidence, type of hemorrhage, treatment modalities, and outcomes.

METHODS

Healthcare Cost and Utilization Project's Florida State Inpatient Database was queried 2007-2011 for patients undergoing pancreaticoduodenectomy. Characteristics and outcomes were compared by χ². Multivariate logistic regression model was generated for risk of hemorrhage during index visit.

RESULTS

Of 2548 patients, 217 (8.5%) developed post-operative hemorrhage during their index visit with 139 (64.0%) requiring angiographic, endoscopic, or operative intervention. Overall mortality during index visit was 5.7% (146) - significantly higher in those patients who had post-operative hemorrhage (24.9%) vs not (4.0%) (p < 0.0001). Mortality was significantly higher when post-operative hemorrhage occurred during the second (POD 8-14) vs first (POD 0-7) week at 15/28 vs 16/74, respectively (p = 0.007). On multivariate analysis, male sex (OR 1.56, p = 0.003), vascular resection (OR 1.88, p = 0.017), very low hospital volume (≤7 PD/year; OR 1.62, p = 0.016), and post-operative intra-abdominal/wound infection (OR 2.31, p < 0.0001) were independent predictors for risk of hemorrhage during index visit.

CONCLUSIONS

Hemorrhage following pancreaticoduodenectomy remains common, resulting in significantly increased mortality. Hemorrhage during the second post-operative week carries approximately double the mortality of early bleeding, suggesting different etiologies requiring differing treatment approaches.

Factors influencing failure to rescue after pancreaticoduodenectomy: a National Surgical Quality Improvement Project Perspective

BACKGROUND

Failure to rescue is the concept of death after a complication, and it is an important factor driving variation in mortality rates after pancreatic surgery. The purpose of this study was to conduct a retrospective review of a large, multi-institutional data set to describe patient-level risk factors for failure to rescue in greater detail.

METHODS

From the American College of Surgeons National Surgical Quality Improvement Program participant use file, 14,557 patients who underwent pancreaticoduodenectomy were identified. Of these, 4514 experienced at least one complication and were therefore at risk for failure to rescue. Multivariable logistic regression models to identify factors independently associated with failure to rescue.

RESULTS

Age, American Society of Anesthesiologists class, ascites and/or varices, and disseminated malignancy were significant independent risk factors for failure to rescue. Participation of a resident was associated with reduced odds of failure to rescue. Patients who experienced an initial complication and then accumulated additional complications were more common in the failure to rescue group (68.6% versus 31.3%, P < 0.001).

CONCLUSIONS

Accumulation of complications after pancreaticoduodenectomy is a significant risk factor for failure to rescue. Pancreatic surgery quality improvement programs should continue developing strategies to identify and intervene on post-pancreatectomy complications, especially in high-risk patients.

Increased morbidity and mortality of a concomitant colectomy during a pancreaticoduodenectomy: an NSQIP propensity-score matched analysis

BACKGROUND

Select patients with peri-ampullary cancers require concomitant colon resection (CR) during a pancreaticoduodenectomy (PD) for margin-negative resections. This study analysed the impact of concomitant CR on major morbidity (MM) and mortality.

METHODS

National Surgical Quality Improvement Program (NSQIP) patients undergoing PD for peri-ampullary cancers were identified from 2005 to 2012. A 4 : 1 propensity-score matched analysis isolated the impact of CR upon PD. Risk factors for 30-day MM and mortality were analysed to determine post-operative sequelae of PD+CR.

RESULTS

From 10 965 PD and 159 PD+CR patients, 624 and 156, respectively, were selected for 4 : 1 matched analysis. PD+CR resulted in a higher MM and mortality (50.0% and 9.0%) versus PD alone (28.8% and 2.9%, respectively, P < 0.001). Multivariate analysis identified risk factors for MM after PD: concomitant CR [odds ratio (OR)-3.19, P < 0.001], smoking (OR-1.92, P = 0.005), a lack of functional independence (OR-3.29, P = 0.018), cardiac disease (OR-2.39, P = 0.011), decreased albumin (per g/dl, OR-1.38, P = 0.033) and a longer operative time (versus median time, OR-1.56, P = 0.029). Independent predictors of mortality included concomitant CR (OR-3.16, P = 0.010), ventilator dependence (OR-13.87, P < 0.001) and septic shock (OR-6.02, P < 0.001).

CONCLUSIONS

CR was an independent predictor of MM and mortality after a PD. Patients requiring PD+CR should be identified pre-operatively, maximally optimized and referred to experienced surgeons at expert centres.

Does Pancreatic Stump Closure Method Influence Distal Pancreatectomy Outcomes?

BACKGROUND

Pancreatic fistula remains the primary source of morbidity following distal pancreatectomy. Previous studies have reported specific methods of parenchymal transection/stump sealing in an effort to decrease the pancreatic fistula rate with highly variable results. The aim of this study was to determine postoperative outcomes following various pancreatic stump-sealing methods.

STUDY DESIGN

All cases of distal pancreatectomy were reviewed at a single institution between January 2008 and June 2011 and were monitored with complete 30-day outcomes through ACS-NSQIP. Pancreatic stump-sealing method was used to create three operation groups (suture, staple, or saline-linked radiofrequency). Two- and three-way statistical analyses were performed among the operation groups.

RESULTS

Two hundred three patients underwent distal pancreatectomy. The most common diagnoses included chronic pancreatitis, adenocarcinoma, and IPMN. The suture, staple, and SLRF groups included 90 (44%), 61 (30%), and 52 (26%) patients, respectively. Overall complications (range 31-38%) and pancreatic fistula (range 25-26%) were similar with each pancreatic closure technique. Operative technique was not associated with an increased need for postoperative interventions or hospital readmission.

CONCLUSIONS

Postoperative outcomes after distal pancreatectomy are unaffected by the use of SLRF sealing of the pancreatic stump when compared to traditional suture or reinforced stapling techniques.

Morbidity and mortality of pancreaticoduodenectomy for benign and premalignant pancreatic neoplasms

OBJECTIVES

Patients with benign neoplasms of the pancreas are selected for pancreaticoduodenectomy if there is concern for malignant transformation. This study compares outcomes after pancreaticoduodenectomy for patients with premalignant and malignant pancreatic neoplasms.

STUDY DESIGN

This retrospective cohort study included all patients who underwent pancreaticoduodenectomy for histologically confirmed benign/premalignant pancreatic neoplasms and primary pancreatic malignancy reported to National Surgical Quality Improvement Program (NSQIP) from 2005 to 2011. Patient characteristics, intraoperative and postoperative morbidity and mortality were compared.

RESULTS

A total of 6085 patients underwent pancreaticoduodenectomy: 744 (12.2 %) for benign/premalignant and 5341 (87.8 %) for malignant pancreatic neoplasms. Patients with benign/premalignant neoplasms were more commonly female, had lower American Society of Anesthesiologists (ASA) class, and were less likely to have major comorbidities (all p ≤ 0.003). After resection, patients with benign/premalignant neoplasms were more likely to develop organ space infection (13.4 vs. 8.5 %, p < 0.001) and sepsis (12.2 vs. 9.2 %, p = 0.009). Cardiovascular, pulmonary, renal, and other organ system complications (p = 0.12) as well as 30-day mortality (3.0 vs. 2.0 %, p = 0.128) did not differ.

CONCLUSIONS

Organ space infection and sepsis are more common after pancreaticoduodenectomy for benign/premalignant neoplasms. Planned improvements in NSQIP data capture should allow for better measurement of this morbidity. A carefully balanced risk and benefit discussion should precede resection in these patients.

Reducing Readmissions after Pancreatectomy: Limiting Complications and Coordinating the Care Continuum

BACKGROUND

Recent analyses of gastrointestinal operations document that complications are a key driver of readmissions. Pancreatectomy is a high outlier with respect to readmission. This analysis sought to determine if a multifactorial approach could reduce readmissions after pancreatectomy.

STUDY DESIGN

From 2007 to 2012, the number of patients readmitted by 30 days after pancreaticoduodenectomy, and distal and total pancreatectomy was measured. Steps to decrease readmissions were implemented independently at 1-year intervals; these efforts included strategies to reduce complications, creation of a Readmissions Team with a "discharge coach," increased use of home health, preferred relationships with post-acute care facilities, and the adoption of "Project RED" (Re-Engineered Discharge). The ACS NSQIP was used to track 30-day outcomes for all pancreatic resections. The University HealthSystem Consortium was used to determine length of stay index.

RESULTS

Over 5 years, 1,163 patients underwent proximal (66%), distal (32%), or total pancreatectomy (2%). The observed 30-day mortality was 2.9% for the study period, and the length of stay index (observed/expected days) was 1.10. Neither varied significantly over time. However, 30-day morbidity decreased from 57% to 46%, and proportion of patients with 30-day all-cause readmissions decreased from 23.0% to 11.5% (p = 0.001).

CONCLUSIONS

All-cause 30-day readmissions after pancreatectomy decreased without increasing length of stay. Efforts by surgeons to decrease complications and an increased emphasis on coordination of care may be useful for reducing readmissions.