Establishing a new pancreatic surgery program in the community setting (our open and robotic experience)

Abstract

Presenter: Jane Han MD | St. Elizabeth Youngstown Hospital Background: The hepato-pancreato-biliary (HPB) subspecialty has predominantly been centered around large academic centers. We believe expansion into the community setting is possible with equivalent surgical outcomes. Methods: This is a single institution, single surgeon, ongoing prospective study from February 2017 up to March 2020. The pancreatic program was started in a Level 1 trauma community teaching hospital with 305 acute care beds located 70 miles from four major academic institutions with established HPB programs. Total open and robotic pancreatic cases were assessed with all robotic cases performed on the DaVinci Xi platform. All patients were placed on an enhanced recovery after surgery protocol. Outcomes measured were R1 resections, reoperations, biochemical pancreatic leaks, post operative pancreatic fistulas (POPF), bile leak, surgical site infections (SSI), delayed gastric emptying (DGE), Clavien-Dindo grade III-IV complications, length of stay (LOS), hospital readmissions, and 30 and 90 day mortalities respectively. Results: Prior to February 2017, our institution had low to no volume in pancreatic surgeries. Since the HPB program was started, 64 patients have undergone pancreatic surgery with zero 90-day mortalities. The 38 pancreaticoduodenectomies (PD) were all performed open. Of the 16 distal pancreatectomy with splenectomies (DPS) performed, 5 were open and 11 were robotic. There were 7 robotic transgastric pancreatic necrosectomy with cyst gastrostomies (PNCG), all performed between March 2019 to March 2020, and 1 open pancreatic necrosectomy with Roux-en-Y cyst jejunostomy. Additionally, 1 duodenum-preserving pancreatic head resection and 1 total pancreatectomy were performed. Of our PD patients, 13% had an R1 resection, 5% required reoperation, 11% had a biochemical pancreatic leak with 5% progressing to POPF, none had a bile leak, 5% developed an SSI, 26% had DGE, 13% had a Clavien-Dindo grade III-IV complication, their mean LOS was 8 days, 21% had a readmission, and none had a 30 or 90 day mortality. Positive correlations were found with POPF and SSI (p=0.0036), POPF and DGE (p=0.0346), and DGE and LOS (p=0.0345); however, POPF was not related to LOS (p=0.1653). SSI, biochemical pancreatic leak, POPF, and Clavien-Dindo grade III-IV were associated with readmissions (p=0.0049, 0.0051, 0.0049, and 0.0005, respectively). The mean operative time was 444 minutes with an estimated blood loss (EBL) of 697 ± 546 mL. Our DPS patients had a biochemical leak rate of 31%, a mean LOS of 6 days, and a 13% readmission rate. There were zero instances of R1 resection (all were R0), reoperation, POPF, SSI, DGE, or Clavien-Dindo grade III-IV complication. The mean operative time was 286 minutes with an EBL of 306 mL. Among robotic PNCG patients, there were no accounts of reoperation, biochemical pancreatic leak, POPF, SSI, or DGE. There was one Clavien-Dindo grade III-IV complication which resulted in a readmission. The mean operative time was 190 minutes with an EBL of 40 mL. Conclusion: Establishing a quality pancreatic surgery program in a community teaching hospital is feasible as long as outcomes reflect those seen nationally.