Hepatopancreatoduodenectomy in North America: are the outcomes acceptable?

Abstract

Background: Major hepatectomy and pancreatoduodenectomy have become safe operations in developed Eastern and Western countries. Most reports of hepatopancreatoduodenectomy (HPD) come from Asia. Historically, the morbidity and mortality of HPD were very high, but recent single institution Asian reports suggest improvement. To date, no Western data with HPB-specific complications have been available to assess the outcomes of HPD. The aim of this analysis was to compare the outcomes of HPD to those of major hepatectomy and pancreatoduodenectomy in North America. Methods: The 2014–16 ACS-NSQIP Procedure-Targeted Participant Use Files were queried for major hepatectomy, pancreatoduodenectomy (PD) and HPD. For major hepatectomy (MH), only right hepatectomy, left hepatectomy and trisegmentectomy (CPT code) procedures were included. For HPD, the MG and PD operations had to be performed concurrently. Partial hepatectomies, wedge liver biopsies, distal pancreatectomies, pancreatic enucleations and total pancreatectomies were excluded. Propensity score matching was utilized to compare HPD procedures with MH (4:1) and PD (6:1) operations. Matching included 33 general demographic, comorbidity, laboratory, operative and pathologic variables. Multiple surgical outcomes were compared by Wilcoxon rank-sum, chi-squared and Fisher’s exact tests where appropriate. Results: Over a three-year period, only 23 HPD procedures were performed. During the same time, 3,893 MHs and 10,583 PDs were available for comparison. With the extensive matching process, 92 MHs and 138 PDs were chosen for comparison. The four most frequent indications for surgery were cholangiocarcinomas, pancreatic malignancies, benign disorders and neuroendocrine tumors. The overall morbidity and mortality for HPD were 87% and 26%, respectively, and were significantly higher (p < 0.01) compared to MH, PD or both (Table). Similarly, serious morbidity, including organ space infections, septic shock, prolonged ventilation and renal failure, was significantly (p < 0.01) greater in patients undergoing HPD. Liver failure also was more common (p < 0.01) in HPD patients, but pancreatic fistula rates were similar. Median length of stay was more than twice as long (p < 0.01) in patients undergoing HPD. Conclusion: Hepatopancreatoduodenectomy (HPD) is rarely performed in North America. During a three year period, only 23 HPDs were undertaken compared to thousands of major hepatectomies (MHs) and pancreatoduodenectomies (PDs). Overall and serious morbidity were more than 80% for HPD, and one-quarter of the patients died after this operation. Major infections and multiple organ failure are the complications which lead to death. These outcomes are unacceptably high and help to explain why HPD is performed so infrequently in North America. Centralization of HPD to a very few centers may be a strategy to improve outcomes.