Peer review of mortality after pancreaticoduodenectomy in Australia

Abstract

Introduction: The data within the Australian and New Zealand Audit of Surgical Mortality (ANZASM) provides a unique opportunity to consider the contributing factors to perioperative deaths as determined by peer review. ANZASM considers all deaths following a surgical admission in Australia. Consideration of the factors contributing to mortality after pancreaticoduodenectomy (PD) can provide greater insight into how deaths can be prevented. Method: ANZASM data from 1 January 2010 to 30 Jun 2017 was reviewed and all deaths following PD were selected for analysis. As a part of the audit process, assessors determine significant clinical events relevant to the patient’s care and classify these into a level of seriousness. Assessor’s determination of whether management could have been improved were reviewed and classified into groups of significant clinical events using thematic analysis with a data driven approach. Result: The study included 87 deaths reported to ANZASM after PD. A return to theatre was reported in 58% of patients. Major complications such as post operative haemorrhage and intraoperative vascular injury occured in 20% and 10% of patients respectively. The assessor determined that there was a delay in recognising a significant complication in 21% of patients. In 17% of patients, ANZASM assessment questioned the decision to operate. Conclusion: This study sought to summarise the significant clinical events leading to mortality after PD in Australia. The large proportion of patients where the decision to operate or proceed was questioned by assessors was a concerning feature. Multi-disciplinary decision making is strongly recommended when deciding which patients to treat with PD. The finding of nearly a quarter of deaths being assessed to be associated with late recognition of complications warrants consideration for surgeons involved in PD.