Quality Indicators in Pancreatic Surgery: Lessons Learned from the German DGAV StuDoQ|Pancreas Registry

The impact of surgical-oncologic textbook outcome in patients with stage I to III pancreatic ductal adenocarcinoma: A cross-validation study of two national registries

BACKGROUND

Using national registries, we aimed to evaluate oncologic textbook outcomes in pancreatic ductal adenocarcinoma patients.

METHODS

Patients with stage I to III pancreatic ductal adenocarcinoma and surgical resection from 2010 to 2020 in the US and Germany were identified using the National Cancer Database and National Cancer Registries data. The surgical-oncologic textbook outcome was defined as complete oncologic resection with no residual tumor and ≥12 harvested lymph nodes. The composite endpoint was defined as surgical-oncologic textbook outcome and receipt of perioperative systemic and/or radiation therapy.

RESULTS

In total, 33,498 patients from the National Cancer Database and 14,589 patients from the National Cancer Registries were included. In the National Cancer Database, 28,931 (86%) patients had complete oncologic resection with no residual tumor, and 11,595 (79%) in the National Cancer Registries. 8,723 (26%) patients in the National Cancer Database and 556 (4%) in the National Cancer Registries had <12 lymph nodes harvested. The National Cancer Database shows 26,135 (78%) underwent perioperative therapy and 8,333 (57%) in the National Cancer Registries. Surgical-oncologic textbook outcome was achieved in 21,198 (63%) patients in the National Cancer Database and in 11,234 (77%) patients from the National Cancer Registries. 16,967 (50%) patients in the National Cancer Database and 7,878 (54%) patients in the National Cancer Registries had composite textbook outcome. Median overall survival in patients with composite textbook outcomes was 32 months in the National Cancer Database and 27 months in the National Cancer Registries (P < .001). In contrast, those with non-textbook outcomes had a median overall survival of 23 months in the National Cancer Database and 20 months in the National Cancer Registries (P < .001).

CONCLUSION

Surgical-oncologic textbook outcomes were achieved in > 50% of stage I to III pancreatic ductal adenocarcinoma for both the National Cancer Database and the National Cancer Registries. Failure to achieve textbook outcomes was associated with impaired survival across both registries.

Recent onset diabetes is associated with better survival in pancreatic ductal adenocarcinoma-An analysis of preoperative symptoms within the DGAV StuDoQ|Pancreas Registry

BACKGROUND

This multicenter study analyzed the relationship between preoperative symptoms and postsurgical outcomes utilizing the German national DGAV StuDoQ|Pancreas database.

METHODS

This retrospective study included 2,643 pancreatic ductal adenocarcinoma patients undergoing pancreatic head resection from 2013-2017 within the German pancreatic surgery registry (DGAV StuDoQ|Pancreas). The association of preoperative symptoms with overall survival was analyzed using Kaplan-Meier and Cox regression analysis.

RESULTS

Preoperative symptoms were common, with 2,380 of 2,643 (90%) patients presenting with any one or more of the following symptoms: jaundice (40%), biliary obstruction treated with biliary stent (41%), pain (37%), weight loss (29%), nausea (18%), diabetes (31%), emesis (6%), and recent onset diabetes (5%). Patients were separated into 3 groups: no symptoms (n = 293), symptoms (n = 2,229), and recent onset diabetes (n = 121). The 3 groups differed in body mass index and nodal staging, where patients with recent onset diabetes had the highest values (body mass index: no symptoms: 24.5 kg/m2, symptoms: 25.1 kg/m2; recent-onset diabetes: 26.3 kg/m2, P = .007), (no symptoms: N1: 55%, N2: 10%; symptoms: N1: 53%, N2: 17%; recent-onset diabetes: N1: 56%, N2: 16%, P = .023). Other pathological characteristics, carbohydrate antigen 19-9 levels, and adjuvant chemotherapy receival did not differ between the groups. Interestingly, recent-onset diabetes was associated with better survival compared with the other groups (Median overall survival: 28 months [no symptoms at all], 22 months [symptoms] versus not reached [recent onset diabetes group], and 5-year overall survival rates of 28%, 11%, and 57%, respectively [log rank, P = .013]). Multivariable analysis revealed that recent-onset diabetes and preoperative symptoms were independently associated with overall survival (recent-onset diabetes, relative risk 0.052 P = .027, >5 symptoms relative risk 3.66, P < .001).

CONCLUSION

Pancreatic ductal adenocarcinoma symptoms occured in up to 90% of patients with resectable pancreatic ductal adenocarcinoma. In addition, PDAC symptoms were associated with overall survival and might identify unique pancreatic ductal adenocarcinoma subtypes.

Defining Benchmark Outcomes for Distal Pancreatectomy: Results of a French Multicentric Study

OBJECTIVE

Defining robust and standardized outcome references for distal pancreatectomy (DP) by using Benchmark analysis.

BACKGROUND

Outcomes after DP are recorded in medium or small-sized studies without standardized analysis. Therefore, the best results remain uncertain.

METHODS

This multicenter study included all patients undergoing DP for resectable benign or malignant tumors in 21 French expert centers in pancreas surgery from 2014 to 2018. A low-risk cohort defined by no significant comorbidities was analyzed to establish 18 outcome benchmarks for DP. These values were tested in high risk, minimally invasive and benign tumor cohorts.

RESULTS

A total of 1188 patients were identified and 749 low-risk patients were screened to establish Benchmark cut-offs. Therefore, Benchmark rate for mini-invasive approach was ≥36.8%. Benchmark cut-offs for postoperative mortality, major morbidity grade ≥3a and clinically significant pancreatic fistula rates were 0%, ≤27%, and ≤28%, respectively. The benchmark rate for readmission was ≤16%. For patients with pancreatic adenocarcinoma, cut-offs were ≥75%, ≥69.5%, and ≥66% for free resection margins (R0), 1-year disease-free survival and 3-year overall survival, respectively. The rate of mini-invasive approach in high-risk cohort was lower than the Benchmark cut-off (34.1% vs ≥36.8%). All Benchmark cut-offs were respected for benign tumor group. The proportion of benchmark cases was correlated to outcomes of DP. Centers with a majority of low-risk patients had worse results than those operating complex cases.

CONCLUSION

This large-scale study is the first benchmark analysis of DP outcomes and provides robust and standardized data. This may allow for comparisons between surgeons, centers, studies, and surgical techniques.

A core set of quality performance indicators for HPB procedures: a global consensus for hepatectomy, pancreatectomy, and complex biliary surgery

BACKGROUND

Surgery for hepatopancreaticobiliary (HPB) conditions is performed worldwide. This investigation aimed to develop a set of globally accepted procedural quality performance indicators (QPI) for HPB surgical procedures.

METHODS

A systematic literature review generated a dataset of published QPI for hepatectomy, pancreatectomy, complex biliary surgery and cholecystectomy. Using a modified Delphi process, three rounds were conducted with working groups composed of self-nominating members of the International Hepatopancreaticobiliary Association (IHPBA). The final set of QPI was circulated to the full membership of the IHPBA for review.

RESULTS

Seven "core" indicators were agreed for hepatectomy, pancreatectomy, and complex biliary surgery (availability of specific services on site, a specialised surgical team with at least two certified HPB surgeons, a satisfactory institutional case volume, synoptic pathology reporting, undertaking of unplanned reintervention procedures within 90 days, the incidence of post-procedure bile leak and Clavien-Dindo grade ≥III complications and 90-day post-procedural mortality). Three further procedure specific QPI were proposed for pancreatectomy, six for hepatectomy and complex biliary surgery. Nine procedure-specific QPIs were proposed for cholecystectomy. The final set of proposed indicators were reviewed and approved by 102 IHPBA members from 34 countries.

CONCLUSIONS

This work presents a core set of internationally agreed QPI for HPB surgery.

Outcomes and risks in palliative pancreatic surgery: an analysis of the German StuDoQ|Pancreas registry

Background

Non-resectability is common in patients with pancreatic ductal adenocarcinoma (PDAC) due to local invasion or distant metastases. Then, biliary or gastroenteric bypasses or both are often established despite associated morbidity and mortality. The current study explores outcomes after palliative bypass surgery in patients with non-resectable PDAC.

Methods

From the prospectively maintained German StuDoQ|Pancreas registry, all patients with histopathologically confirmed PDAC who underwent non-resective pancreatic surgery between 2013 and 2018 were retrospectively identified, and the influence of the surgical procedure on morbidity and mortality was analyzed.

Results

Of 389 included patients, 127 (32.6%) underwent explorative surgery only, and a biliary, gastroenteric or double bypass was established in 92 (23.7%), 65 (16.7%) and 105 (27.0%). After exploration only, patients had a significantly shorter stay in the intensive care unit (mean 0.5 days [SD 1.7] vs. 1.9 [3.6], 2.0 [2.8] or 2.1 [2.8]; P < 0.0001) and in the hospital (median 7 days [IQR 4–11] vs. 12 [10–18], 12 [8–19] or 12 [9–17]; P < 0.0001), and complications occurred less frequently (22/127 [17.3%] vs. 37/92 [40.2%], 29/65 [44.6%] or 48/105 [45.7%]; P < 0.0001). In multivariable logistic regression, biliary stents were associated with less major (Clavien–Dindo grade ≥ IIIa) complications (OR 0.49 [95% CI 0.25–0.96], P = 0.037), whereas—compared to exploration only—biliary, gastroenteric, and double bypass were associated with more major complications (OR 3.58 [1.48–8.64], P = 0.005; 3.50 [1.39–8.81], P = 0.008; 4.96 [2.15–11.43], P < 0.001).

Conclusions

In patients with non-resectable PDAC, biliary, gastroenteric or double bypass surgery is associated with relevant morbidity and mortality. Although surgical palliation is indicated if interventional alternatives are inapplicable, or life expectancy is high, less invasive options should be considered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-022-01833-3.

Umbilical incisional hernias (M3): are trocar-site hernias different? Comparative analysis of the EVEREG registry⋆

BACKGROUND

Incisional hernia (HI), in open and laparoscopic surgery, is a very frequent complication. HI located in the umbilical region are called M3. The main aim of this study is to compare HI produced by the placement of an umbilical laparoscopic trocar (M3T) with those located in M3 in open surgery (M3O) in terms of basal characteristics, complications and recurrences; and secondarily the identification of risk factors.

METHOD

Cross-sectional observational study based on the national prospective registry EVEREG during the period of July 2012-June 2018. The main variables were recurrences and postoperative complications. Both groups (M3T and M3O) were compared. Multiple logistic regression was performed to identify the risk factors of the entire cohort.

RESULTS

882 had a follow-up time longer than 12 months. M3O group presented superior ASA-Class, more complex HI and previous repair. It also presented a higher recurrence rate at 12 and 24 months (8.6% vs. 2.5%; P < 0,0001 and 9.3% vs. 2.9%; P < 0.0001) and higher postoperative complications rate (21.9% vs. 14.6 %; P = 0.02). Previous repair, intervention length and associated procedures requirement were identified as risk factors for postoperative complications. Absence of a specialist present during surgery, previous repair, and the absence of complications were identified as risk factors for recurrence. In the PSM analysis no differences were detected in of complications and recurrences.

CONCLUSIONS

HI M3O is more complex than M3T. The complexity is not related to the origin of the hernia but to its characteristics and those of the patient.

Robotisch gestützte Enukleation einer zystischen Neoplasie des Pankreaskopfes

Laut aktuellen revidierten Fukuoka-Leitlinien besteht die Indikation zur Resektion von BD-IPMN des Pankreas mit Worrisome Features, da hier ein Risiko der malignen Entartung von bis zu 30% besteht. Die Resektion kann bei fehlenden klinischen, bildmorphologischen und laborchemischen Malignitätszeichen als eine nicht anatomische, lokale Exzision durchgeführt werden.

Eine robotische Enukleation bei benignen Raumforderungen der Bauchspeicheldrüse stellt eine sehr gute Alternative zu den resezierenden Verfahren, insbesondere zu denjenigen in offener Technik, dar. Diese operative Behandlungsoption wird bei einem Mindestabstand bis zum pankreatischen Hauptgang von mindestens 2 mm im „International consensus statement on robotic pancreatic surgery“ nahegelegt.

Neben den bekannten Vorteilen der minimalinvasiven Chirurgie führt diese parenchymsparende Methode zum Erhalt von endo- und exokriner Funktion (ca. 90%) und zu einem progressfreien 10-Jahres-Überleben von ca. 75% bei etwas erhöhter Morbidität (ca. 60%) verglichen mit den resezierenden Verfahren.

Der folgende Videobeitrag präsentiert das Operationsvideo einer robotischen Zystenenukleation (bei Verdacht auf eine BD-IPMN mit Worrisome Features) im Pankreaskopf und Processus uncinatus bei einer 62-jährigen Patientin mit besonderer Betonung der wichtigsten vaskulären Landmarken, Besonderheiten der Herangehensweise und Vorteile der robotischen Technik.

[Incidence, Treatment and Survival in Pancreatic Cancer- Data of the Nationwide Oncological Quality Conference from a Surgical Perspective]

BACKGROUND

In recent years, there have been changes in the treatment of ductal pancreatic carcinoma with regard to multimodal therapy and also surgical therapy. These changes have not yet been explored in large nationwide studies in Germany. The present work gives an initial overview from a surgical perspective of the developments in diagnosis, therapy and survival of pancreatic cancer within the last 19 years in Germany.

METHODS

In this cohort of 18 clinical cancer registries in Germany, patients with a diagnosis of ductal pancreatic cancer from 2000-2018 were included. The patients were categorised according to the years of diagnosis (2000-2009 vs. 2010-2018) and treatment modalities and compared.

RESULTS

In the cohort of approx. 48000 patients with ductal pancreatic cancer, the number of newly diagnosed cases increased from approx. 18000 to 30000 patients in the two ten-year periods. The median overall survival increased slightly but statistically significantly from 7.1 to 7.9 months (p < 0.001). The resection rate increased from 25% to 32%, with the proportion of patients for whom no specific therapy was reported decreased by 11%. The rate of palliative chemotherapy and neoadjuvant chemotherapy also increased from 16% to 20% of the patients and from less than 1% to 2% of the patients, respectively. The median survival in the curatively treated subgroups was up to 24 months.

SUMMARY

The cancer registry data appear to confirm the known increase in the incidence of pancreatic cancer in the western world. Resection rates and the rates of treatment with neoadjuvant and palliative intent also increased. The overall survival of all patients with ductal pancreatic cancer only increased marginally. In the subgroups of patients who were treated with curative intent, however, significantly longer survival times were found.

Pylorus resection versus pylorus preservation in pancreatoduodenectomy (PyloResPres): study protocol and statistical analysis plan for a German multicentre, single-blind, surgical, registry-based randomised controlled trial

INTRODUCTION

Partial pancreatoduodenectomy (PD) is the treatment of choice for various benign and malignant tumours of the pancreatic head or the periampullary region. For reconstruction of the gastrointestinal passage, two stomach-preserving PD variants exist: pylorus preservation PD (ppPD) or pylorus resection PD (prPD) with preservation of the stomach. In pancreatic surgery, delayed gastric emptying (DGE) remains a serious complication after PD with an incidence varying between 4.5% and 45%, potentially delaying hospital discharge or further treatment, for example, adjuvant chemotherapy. Evidence is lacking to assess, which variant of PD entails fewer postoperative DGE.

METHODS AND ANALYSIS

The protocol of a large-scale, multicentre, pragmatic, two-arm parallel-group, registry-based randomised controlled trial (rRCT) using a two-stage group-sequential design is presented. This patient-blind rRCT aims to demonstrate the superiority of prPD over ppPD with respect to the overall incidence of DGE within 30 days after index surgery in a German real-world setting. A total of 984 adults undergoing elective PD for any indication will be randomised in a 1:1 ratio. Patients will be recruited at about 30 hospitals being members of the StuDoQ|Pancreas registry established by the German Society of General and Visceral Surgery. The postoperative follow-up for each patient will be 30 days. The primary analysis will follow an intention-to-treat approach and applies a binary logistic random intercepts model. Secondary perioperative outcomes include overall severe morbidity (Clavien-Dindo classification), blood loss, 30-day all-cause mortality, postoperative hospital stay and operation time. Complication rates and adverse events will be closely monitored.

ETHICS AND DISSEMINATION

This protocol was approved by the leading ethics committee of the Medical Faculty of the Ludwig-Maximilians-Universität, Munich (reference number 19-221). The results will be published in a peer-reviewed journal and presented at international conferences. Study findings will also be disseminated via the website (http://www.dgav.de/studoq/pylorespres/).

TRIAL REGISTRATION NUMBER

DRKS-ID: DRKS00018842.

Safety of anastomoses in colorectal cancer surgery in octogenarians: a prospective cohort study with propensity score matching

BACKGROUND

Up to 20 per cent of all operations for patients with colorectal cancer (CRC) are performed in octogenarians. Anastomotic leakage is a leading cause of morbidity and death after resection for CRC. The aim of this study was to assess the rate of anastomosis creation, the risk of anastomotic leakage and death in surgery for left-sided CRC in elderly patients.

METHODS

This prospective cohort study compared patients less than 80 and 80 or more years with left-sided CRC resection performed between 2013 and 2019. Data were provided from a risk-adjusted surgical quality-assessment system with 219 participating centres in Germany. Outcome measures were the rate of anastomoses, anastomotic leakages, death at 30 days and 2-year overall survival (OS). Propensity score matching was used to control for selection bias and compare subgroups of patients of less than 80 and 80 or more years.

RESULTS

Out of 18 959 patients, some 3169 (16.7 per cent) were octogenarians. Octogenarians were less likely to receive anastomoses (82.0 versus 92.9 per cent, P < 0.001; odds ratio 0.50 (95 per cent c.i. 0.44 to 0.58), P < 0.001). The rate of anastomotic leakages did not differ between age groups (8.6 versus 9.7 per cent, P = 0.084), but 30-day mortality rate after leakage was significantly higher in octogenarians (15.8 versus 3.5 per cent, P < 0.001). Overall, anastomotic leakage was the strongest predictor for death (odds ratio 4.95 (95 per cent c.i. 3.66 to 6.66), P < 0.001). In the subgroup with no leakage, octogenarians had a lower 2-year OS rate than younger patients (71 versus 87 per cent, P < 0.001), and in the population with anastomotic leakage, the 2-year OS was 80 per cent in younger and 43 per cent in elderly patients (P < 0.001). After propensity score matching, older age remained predictive for not receiving an anastomosis (odds ratio 0.54 (95 per cent c.i. 0.46 to 0.63), P < 0.001) and for death (odds ratio 2.60 (95 per cent c.i. 1.78 to 3.84), P < 0.001), but not for the occurrence of leakages (odds ratio 0.94 (95 per cent c.i. 0.76 to 1.15), P = 0.524).

CONCLUSION

Anastomotic leakage is not more common in octogenarians, but an age of 80 years or older is an independent factor for not receiving an anastomosis in surgery for left-sided CRC. The mortality rate in the case of leakage in octogenarians was reported to exceed 15 per cent.

Benchmarking Performance in Pancreatic Surgery: a Systematic Review of Published Quality Metrics

BACKGROUND

Pancreatic surgery is performed in relatively few centres. There are validated quality benchmarks for pancreatic surgery, although it remains unclear how published benchmarks compare with each other. This study aimed to systematically review published literature to summarise metrics that define quality benchmarks for pancreatic surgery.

METHOD

A search of MEDLINE, EMBASE and CENTRAL was undertaken until June 2019. Articles that developed or validated published quality benchmarks for pancreatic surgery were included. Benchmarks were classified into three domains using the Donabedian framework, and their quality assessed using the AIRE Instrument.

RESULTS

Nineteen studies included 55 quality metrics, of which 8 developed new metrics, and 11 studies validated previously published metrics. The methodology of metric development was either expert opinion-driven or data-driven. All metrics demonstrated moderate quality scores. There was partial agreement in some metrics (e.g. < 10 h total operative duration), but lack of consensus for most others (e.g. lymph node yield ≥ 10, ≥ 12, ≥ 15, ≥ 16). No metrics related to patient reported outcomes.

CONCLUSIONS

Published quality benchmarks for pancreatic surgery predominantly arise from eight studies, with heterogeneity in how the metrics were developed. There was not consensus for all metrics. Metrics need to be reviewed as new data emerge, technologies develop and opinions change.

Umbilical incisional hernia (M3) Are trocar hernia differents? Comparative analysis of the EVEREG Registry

INTRODUCTION

Incisional hernia (HI), in open and laparoscopic surgery, is a very frequent complication. HI located in the umbilical region are called M3. The main aim of this study is to compare HI produced by the placement of an umbilical laparoscopic trocar (M3T) with those located in M3 in open surgery (M3O) in terms of basal characteristics, complications and recurrences; and secondarily the identification of risk factors.

METHOD

Cross-sectional observational study based on the national prospective registry EVEREG during the period of July 2012 - June 2018. The main variables were recurrences and postoperative complications. Both groups (M3T and M3O) were compared. Multiple logistic regression was performed to identify the risk factors of the entire cohort.

RESULTS

882 had a follow-up time longer than 12 months. M3O group presented superior ASA-Class, more complex HI and previous repair. It also presented a higher recurrence rate at 12 and 24 months (8.6 vs. 2.5%; p < 0,0001 and 9.3 vs. 2.9%; p < 0.0001) and higher postoperative complications rate (21.9 vs. 14.6%; p = 0.02). Previous repair, intervention length and associated procedures requirement were identified as risk factors for postoperative complications. Absence of a specialist present during surgery, previous repair, and the absence of complications were identified as risk factors for recurrence. In the PSM analysis no differences were detected in of complications and recurrences.

CONCLUSIONS

HI M3O is more complex than M3T. The complexity is not related to the origin of the hernia but to its characteristics and those of the patient.

Quality performance indicators for hepato-pancreatico-biliary procedures: a systematic review

BACKGROUND

This systematic review was undertaken to define and summarize existing, proposed quality performance indicators (QPI) for hepato-pancreatico-biliary (HPB) procedures.

METHODS

A systematic literature review identified studies reporting on quality indicators for cholecystectomy, hepatectomy, pancreatectomy and complex biliary surgical procedures. The databases searched were MEDLINE, EMBASE, PubMed, and SCOPUS, with all literature available until the search date of 1 May 2020 included. The reference lists of all included papers, as well as related review articles, were manually searched to identify further relevant studies.

RESULTS

Forty-five publications report quality indicators for pancreatectomy (n = 22), hepatectomy (n = 7), HPB resections in general (n = 12), and cholecystectomy (n = 6). No publications proposed QPI for complex biliary surgery. The 45 papers used national audit (n = 18), consensus methodology (n = 5), state-wide audit (n = 3), unit audit (n = 9), review methodology (n = 9), and survey methodology (n = 1). Sixty-one QPI were reported for pancreatectomy, 22 reported for hepatectomy, and 14 reported for HPB resections in general, in domains of infrastructure, provider, and documentation. Fourteen infrastructure and provider-based QPI were reported for cholecystectomy.

CONCLUSIONS

There are few internationally agreed QPI for HPB procedures that allow global comparison of provider performance and that set aspirational goals for patient care and experience.

Outcome Quality Beyond the Mean - An Analysis of 43,231 Pancreatic Surgical Procedures Related to Hospital Volume

OBJECTIVE

The aim of this study was to examine whether elevated in-hospital mortality rates in lower volume hospitals are only valid on average or also apply for individual hospitals.

SUMMARY OF BACKGROUND DATA

Various studies demonstrated a volume-outcome relationship in pancreatic surgery with increased mortality in low volume hospitals. However, almost all studies assessed quality indicators only for groups of hospitals by averaged measures, neglecting variability of hospital performance.

METHODS

The German nationwide hospital discharge data (diagnosis-related groups-statistics) was used to determine risk-adjusted in-hospital mortality for all distal pancreatectomies (DP), pancreatoduodenectomies (Whipple-procedure, PD), and pylorus-preserving pancreatoduodenectomies (PPD) performed between 2011 and 2015. Hospitals were stratified according to annual and 5-year total procedure volume and examined in relation to average in-hospital mortality of the highest volume quintile.

RESULTS

Lowest adjusted mortality rates were observed in highest volume quintiles for each pancreatic resection procedure, with 6.2% for DP, 8.3% for PD, and 5.7% for PPD in the 5-year observation period. With these mortality rates as reference values the analysis revealed that a non-negligible proportion of hospitals performed equal or better (DP: 430/784, 54.5%; PD: 269/611, 44.0%; PPD: 255/565, 45.1%) than the hospitals of the highest volume quintile.

CONCLUSIONS

High quality of care, with in-hospital mortality rates less or equal to high-volume hospitals, is also achieved in hospitals with lesser procedure volume. Therefore, mere volume seems not suitable as proximal measure for assessing individual hospital quality. Instead, more sophisticated certification systems, that allow accurate quality assessment and better reflect clinical variability, should preferred to fixed minimum volume thresholds.

Microbiome Patterns in Matched Bile, Duodenal, Pancreatic Tumor Tissue, Drainage, and Stool Samples: Association with Preoperative Stenting and Postoperative Pancreatic Fistula Development

Postoperative complications after pancreatic surgery are still a significant problem in clinical practice. The aim of this study was to characterize and compare the microbiomes of different body compartments (bile duct, duodenal mucosa, pancreatic tumor lesion, postoperative drainage fluid, and stool samples; preoperative and postoperative) in patients undergoing pancreatic surgery for suspected pancreatic cancer, and their association with relevant clinical factors (stent placement, pancreatic fistula, and gland texture). For this, solid (duodenal mucosa, pancreatic tumor tissue, stool) and liquid (bile, drainage fluid) biopsy samples of 10 patients were analyzed using 16s rRNA gene next-generation sequencing. Our analysis revealed: (i) a distinct microbiome in the different compartments, (ii) markedly higher abundance of Enterococcus in patients undergoing preoperative stent placement in the common bile duct, (iii) significant differences in the beta diversity between patients who developed a postoperative pancreatic fistula (POPF B/C), (iv) patients with POPF B/C were more likely to have bacteria belonging to the genus Enterococcus, and (v) differences in microbiome composition with regard to the pancreatic gland texture. The structure of the microbiome is distinctive in different compartments, and can be associated with the development of a postoperative pancreatic fistula.

Textbook Outcome: Nationwide Analysis of a Novel Quality Measure in Pancreatic Surgery

BACKGROUND

Textbook outcome (TO) is a multidimensional measure for quality assurance, reflecting the "ideal" surgical outcome.

METHODS

Post-hoc analysis of patients who underwent pancreatoduodenectomy (PD) or distal pancreatectomy (DP) for all indications between 2014 and 2017, queried from the nationwide prospective Dutch Pancreatic Cancer Audit. An international survey was conducted among 24 experts from 10 countries to reach consensus on the requirements for TO in pancreatic surgery. Univariable and multivariable logistic regression was performed to identify TO predictors. Between-hospital variation in TO rates was compared using observed-versus-expected rates.

RESULTS

Based on the survey (92% response rate), TO was defined by the absence of postoperative pancreatic fistula, bile leak, postpancreatectomy hemorrhage (all ISGPS grade B/C), severe complications (Clavien-Dindo ≥III), readmission, and in-hospital mortality. Overall, 3341 patients were included (2633 (79%) PD and 708 (21%) DP) of whom 60.3% achieved TO; 58.3% for PD and 67.4% for DP. On multivariable analysis, ASA class 3 predicted a worse TO rate after PD (ASA 3 OR 0.59 [0.44-0.80]), whereas a dilated pancreatic duct (>3 mm) and pancreatic ductal adenocarcinoma (PDAC) were associated with a better TO rate (OR 2.22 [2.05-3.57] and OR 1.36 [1.14-1.63], respectively). For DP, female sex and the absence of neoadjuvant therapy predicted better TO rates (OR 1.38 [1.01-1.90] and OR 2.53 [1.20-5.31], respectively). When comparing institutions, the observed-versus-expected rate for achieving TO varied from 0.71 to 1.46 per hospital after casemix-adjustment.

CONCLUSIONS

TO is a novel quality measure in pancreatic surgery. TO varies considerably between pancreatic centers, demonstrating the potential benefit of quality assurance programs.

Curative-intent pancreas resection for pancreatic metastases: surgical and oncological results

Background

Pancreatic metastasis is a rare cause for pancreas surgery and often a sign of advanced disease no chance of curative-intent treatment. However, surgery for metastasis might be a promising approach to improve patients’ survival. The aim of this study was to analyze the surgical and oncological outcome after pancreatic resection of pancreatic metastasis.

Methods

This is a retrospective cohort analysis of a prospectively-managed database of patients undergoing pancreatic resection at the University of Freiburg Pancreatic Center from 2005 to 2017.

Results

In total, 29 of 1297 (2%) patients underwent pancreatic resection due to pancreatic metastasis. 20 (69%) patients showed metastasis of renal cell carcinoma (mRCC), followed by metastasis of melanoma (n = 5, 17%), colon cancer (n = 2, 7%), ovarian cancer (n = 1, 3%) and neuroendocrine tumor of small intestine (n = 1, 3%). Two (7%) patients died perioperatively. Median follow-up was 76.4 (range 21–132) months. 5-year and overall survival rates were 82% (mRCC 89% vs. non-mRCC 67%) and 70% (mRCC 78% vs. non-mRCC 57%), respectively. Patients with mRCC had shorter disease-free survival (14 vs. 22 months) than patients with other primary tumor entities.

Conclusion

Despite malignant disease, overall survival of patients after metastasectomy for pancreatic metastasis is acceptable. Better survival appears to be associated with the primary tumor entity. Further research should focus on molecular markers to elucidate the mechanisms of pancreatic metastasis to choose the suitable therapeutic approach for the individual patient.

Indications for resection and perioperative outcomes of surgery for pancreatic neuroendocrine neoplasms in Germany: an analysis of the prospective DGAV StuDoQ|Pancreas registry

PURPOSE

Pancreatic neuroendocrine neoplasms (pNENs) are rare, and their surgical management is complex. This study evaluated the current practice of pNEN surgery across Germany, including its adherence with guidelines and its perioperative outcomes.

METHODS

Patients who underwent surgery for pNENs (April 2013-June 2017) were retrieved from the prospective StuDoQ|Pancreas registry of the German Society of General and Visceral Surgery and retrospectively analyzed.

RESULTS

A total of 287 patients (53.7% male) with a mean age of 59.2 ± 14.2 years old underwent pancreatic resection for pNENs. Tumors were localized in the pancreatic head (40.4%), body (23%), or tail (36.6%). A total of 239 (83.3%) patients underwent formal resection with lymphadenectomy, 40 (14%) parenchyma-sparing resection, and 8 (2.8%) only exploration. Fifty (17.4%) patients underwent a minimally invasive approach. Among the 245 patients with complete pathological information, 42 (17.1%) had distant metastases, 78 (31.8%) had stage I tumors, 74 (30.2%) stage II, and 51 (20.8%) stage III. A total of 112 (45.7%) patients had G1 tumors, 101 (41.2%) G2, and 24 (9.8%) G3. Nodal involvement on imaging was an independent predictor of lymph node metastasis according to the multivariable analysis (odds ratio: 0.057; 95% confidence interval: 0.016-0.209; p < 0.01). R0 resection was reported in 240 (83.6%) patients. The 30- and 90-day mortality rates were 2.8% and 4.2%, respectively.

CONCLUSION

In Germany the rate of potential curative resection for pNEN is high. However, formal pancreatic resection seems to be overrepresented, while minimally invasive resection is underrepresented.

Variation in pancreatoduodenectomy as delivered in two national audits

Background

Nationwide audits facilitate quality and outcome assessment of pancreatoduodenectomy. Differences may exist between countries but studies comparing nationwide outcomes of pancreatoduodenectomy based on audits are lacking. This study aimed to compare the German and Dutch audits for external data validation.

Methods

Anonymized data from patients undergoing pancreatoduodenectomy between 2014 and 2016 were extracted from the German Society for General and Visceral Surgery StuDoQ|Pancreas and Dutch Pancreatic Cancer Audit, and compared using descriptive statistics. Univariable and multivariable risk analyses were undertaken.

Results

Overall, 4495 patients were included, 2489 in Germany and 2006 in the Netherlands. Adenocarcinoma was a more frequent indication for pancreatoduodenectomy in the Netherlands. German patients had worse ASA fitness grades, but Dutch patients had more pulmonary co-morbidity. Dutch patients underwent more minimally invasive surgery and venous resections, but fewer multivisceral resections. No difference was found in rates of grade B/C postoperative pancreatic fistula, grade C postpancreatectomy haemorrhage and in-hospital mortality. There was more centralization in the Netherlands (1·3 versus 13·3 per cent of pancreatoduodenectomies in very low-volume centres; P &lt; 0·001). In multivariable analysis, both hospital stay (difference 2·49 (95 per cent c.i. 1·18 to 3·80) days) and risk of reoperation (odds ratio (OR) 1·55, 95 per cent c.i. 1·22 to 1·97) were higher in the German audit, whereas risk of postoperative pneumonia (OR 0·57, 0·37 to 0·88) and readmission (OR 0·38, 0·30 to 0·49) were lower. Several baseline and surgical characteristics, including hospital volume, but not country, predicted mortality.

Conclusion

This comparison of the German and Dutch audits showed variation in case mix, surgical technique and centralization for pancreatoduodenectomy, but no difference in mortality and pancreas-specific complications.