The beneficial effects of minimizing blood loss in pancreatoduodenectomy

Abstract

Background: The negative impact of intraoperative blood loss on outcomes in pancreatoduodenectomy (PD) has long been suspected but not well characterized, particularly factors that may be within the surgeon's control. Methods: From 2001 to 15, 5323 PDs were performed by 62 surgeons from 17 institutions. Estimated blood loss (EBL) was discretized (0–300, 301–750, 751–1300, and >1300 mL) using optimal scaling methodology. Multivariable regression, adjusted for patient, surgeon, and institution variables, was used to identify associations with EBL zones and perioperative outcomes. Contributors to minimizing EBL were elucidated. Beta coefficient standardization determined the relative impact of surgeon-modifiable contributors. Results: The median EBL of the series was 400 mL (IQR 250–600). Intra-, post-, and perioperative transfusion rates were 15.8, 24.8, and 30.9% respectively. Progressive EBL zones correlated with intra – but not postoperative transfusion in a dose-dependent fashion (R 2 = 0.9128), with a key threshold of 750 mL EBL (8.14% vs 40.9%; p < 0.001). Increasing blood loss significantly correlated with poor perioperative outcomes (Table 1). Factors associated with “increased” EBL were: trans-anastomotic stent use, neoadjuvant chemotherapy, PG reconstruction, multiorgan or vascular resection, and elevated operative time, of which 45.5% of the relative impact was potentially modifiable by the surgeon. Conversely, female gender, small duct, soft gland, minimally invasive approach, pylorus-preservation, biological sealant use, and institutional volume (>67/year) were associated with “decreased” EBL, of which 17.5% was potentially under the surgeon's influence. Conclusion: Minimizing blood loss contributes to fewer intraoperative transfusions and better perioperative outcomes for PD. Improvements might be achieved by targeting modifiable factors that influence EBL.Table 1The Influence of Blood Loss on Perioperative Outcomes Following PDVariablePatientsIntraoperative transfusionAny complication: accordion ≥1Severe complication: accordion ≥3CR-POPFLength of stay >13 days30-day readmission90-day mortalityEBL (mL)(N, %)(OR, 95% CI)(OR, 95% CI)(OR, 95% CI)(OR, 95% CI)(OR, 95% CI)(OR, 95% CI)(OR, 95% CI)0–3002359 (44.3)l (Ref.)1 (Ref.)1 (Ref.)1 (Ref.)l(Ref.)l(Ref.)l(Ref.)301–7502104 (39.5)1.648 (0.897–3.026)1.318* (1.160–1.498)1.132 (0.960–1.334)1.489* (1.222–1.815)1.282* (1.103–1.489)0.945 (0.724–1.234)1.041 (0.648–1.671)751–130053.8 (10-1)6.811* (3.362–13.80)2.015* (1.626–2.496)1.370* (1.062–1.767)1.261 (0.904–1.760)1 667* (1.318–2.108)1.539* (1.063–2.230)1.283 (0.691–2.384)>1300322 (6.1)27.244* (12.525–59.20)2.394* (1.515–3.156)1.876* (1.391–2.528)1.507* (1.017–2.233)2.726* (2.077–3.578)2.247* (1.499–3.369)2.445* (1.269–4.710)*: p < 0.05 Open table in a new tab *: p < 0.05