Pre-operative staging in pancreas cancer within the national surgical quality improvement program database

Abstract

Objective: Routine pre-operative staging in pancreas cancer is controversial. We sought to evaluate the rates of diagnostic laparoscopy (DLAP) and laparotomy without resection (XLAP) for pancreas cancer patients over time. Methods: The National Surgical Quality Improvement Program (NSQIP) was queried for patients with pancreas cancer (2005–2013). Groups were as follows: DLAP, XLAP, pancreas resection (RSXN) or palliative biliary and/or gastroduodenal bypass (PALL). Comparisons were based on demographics, comorbidities, post-operative complications and 30-day mortality (chi-square: P < .05) as well as trends over time (R2: 0–1). Results: Among 18,399 patients, relative frequencies were RSXN: 76.2%, XLAP: 15.4%, PALL: 7.7%, and DLAP: 4.3% with some having multiple CPT codes. Only 2% (n=269) of RSXN patients underwent DLAP prior to resection. Of the remaining DLAP patients, 82% had no other operation. XLAP occurred in 38.8% of non-RSXN patients, of whom 61.3% had no other operation. The percentage of patients undergoing RSXN increased 20.3% over time (R2: 0.81) while DLAP decreased 52.6% (R2:0.92) (Figure). XLAP patients without other operations decreased from 4.2% to 2.4%, although not linearly (R2:0.31). DLAP patients were more often white (91.3% vs. 83.1%, P=.05) and less often hypertensive (49.5% vs. 57.7%, P=.01) than XLAP patients. Wound infection, urinary tract infection and venous thromboembolism were significantly less common with DLAP (all P<.05). 30-day mortality was no different for DLAP (5.1%), XLAP (6.0%) or PALL (6.2%) patients, but was lower for RSXN (2.5%, P < .01). Conclusion: Diagnostic laparoscopy for pancreas malignancy is becoming less common but could benefit a subset of patients who undergo open exploration without resection or palliative bypass.