Open Distal Pancreatectomy Research Articles

Distal pancreatectomy outcomes: Perspectives from a community-based teaching institution.

Backgrounds/AimsDistal pancreatic resections are intricate operations with potential for significant morbidity; there is controversy surrounding the appropriate setting regarding surgeon/hospital volume. We report our distal pancreatectomy experience from a community-based teaching hospital.MethodsThis study includes all patients who underwent laparoscopic distal pancreatectomy (LDP) and open distal pancreatectomy (ODP) for benign and malignant lesions between June 2004 and October 2017. Both groups were compared for perioperative characteristics, parenchymal resection technique, and outcomes.Results138 patients underwent distal pancreatectomy during this time. The distribution of LDP and ODP was 68 and 70 respectively. Operative time (146 vs. 174 min), blood loss (139 vs. 395 ml) and mean length of stay (4.8 vs. 8.0 days) were significantly lower in the laparoscopic group. The 30-day Clavien Grade 2/3 morbidity rate was 13.7% (19/138) and the incidence of Grade B/C pancreatic fistula was 6.5% (9/138), with no difference between ODP and LDP. 30-day mortality was 0.7% (1/138). 61/138 resections had a malignancy on final pathology. ODP mean tumor diameter was greater (6.4 cm vs. 2.9 cm), but there was no significant difference in the mean number of harvested nodes (8.6 vs. 7.4). The cost of hospitalization, including readmissions and surgery was significantly lower for LDP ($7558 vs. $11610).ConclusionsThis series of distal pancreatectomies indicates a shorter hospital stay, less operative blood loss and reduced cost in the LDP group, and comparable morbidity and oncologic outcomes between LDP and ODP. It highlights the feasibility and safety of these complex surgeries in a community setting.

Minimally Invasive Distal Pancreatectomy Is Associated with Decreased Postoperative Neutrophil to Lymphocyte Ratio

Purpose: The neutrophil-to-lymphocyte ratio (NLR) is a marker of inflammation that has been investigated as a prognostic factor in many diseases. We hypothesized that NLR would be lower in patients undergoing minimally invasive distal pancreatectomy (MIDP).Methods: Using a prospective database, we identified patients who underwent open or minimally invasive (laparoscopic/robotic) distal pancreatectomy and splenectomy from 2006 to 2018. Patients were grouped according to their type of surgery and matched by age, gender, and benign or malignant pathology. The NLR was calculated from a complete blood count with differential on the second postoperative day. Statistical calculations were performed in Stata (v13.0).Results: A total of 106 patients were included, with 53 MIDP and 53 open cases. MIDP was associated with a significantly lower postoperative NLR than open surgery (13.3 vs. 17.2, p = 0.01). NLR did not vary significantly between patients who developed complications and those who did not (15.4 vs. 15.3, p = 0.95). Patients undergoing MIDP had decreased length of postoperative hospital stay (4 days vs. 5 days, p = 0.003). Multivariable linear regression failed to find a significant decrease in NLR with the use of laparoscopy (p = 0.14) when accounting for age, body mass index, surgical blood loss, pathology, and operative time as covariates.Conclusion: The NLR is significantly decreased when performing MIDP versus open distal pancreatectomy, but correlation with clinical outcomes has yet to be proven.

Long-term oncologic outcomes of robotic and open pancreatectomy in a national cohort of pancreatic adenocarcinoma.

Robotic pancreatectomy is gaining momentum; however, limited data exist on the long-term survival of this approach for pancreatic ductal adenocarcinoma (PDAC). The objective of this study is to compare the long-term oncologic outcomes of robotic pancreaticoduodenectomy (RPD) and robotic distal pancreatectomy (RDP) to open surgery in patients with PDAC. Robotic and open pancreatectomy for stages I-III PDAC were obtained from the 2010 to 2016 National Cancer Database. We identified 17 831 pancreaticoduodenectomies and 2718 distal pancreatectomies of which 626 (4%) and 332 (12%) were robotic, respectively. There was no difference in median overall survival between RPD (22.0 months) and open pancreatoduodenectomy (21.8 months; logrank P = .755). The adjusted hazard ratio [HR] was 1.014 (95% confidence interval [CI]: 0.903-1.139). The median overall survival for RDP (35.3 months) was higher than open distal pancreatectomy (ODP) (24.9 months; logrank P = .001). The adjusted HR suggests a benefit to RDP compared to ODP (HR, 0.744; 95% CI: 0.632-0.868) CONCLUSION: In a national cohort of resected pancreatic adenocarcinoma, the robotic platform was associated with similar long-term survival for pancreaticoduodenectomy, but improved survival for distal pancreatectomy.

A Novel Technique for Pancreatic Stump Closure: Clip Ligation of the Duct and Associated Suturing of Pancreas.

Pancreatic fistula (PF) remains the primary source of morbidity after distal pancreatectomy (DP). There is currently no optimal stump closure technique to reduce PF rates. We present a novel technique for pancreatic stump closure using Clip Ligation of the duct and Associated Suturing of Pancreas (CLASP). Five patients (three females) with a median age of 65 years underwent DP and splenectomy for pancreatic body or tail tumour using the CLASP technique. Four of those operations were done laparoscopically. Only one patient developed grade A PF. No other postoperative complications were noticed. The mean length of stay was 5.4 days. The CLASP technique was applicable in both laparoscopic and open distal pancreatectomy. The key points include mobilisation of the pancreatic body from the retroperitoneum and division of the parenchyma with energy device. The technique of pancreatic stump closure involves the isolation of the pancreatic duct (PD), application of a double ligaclip on the proximal duct, division of the PD and finally suturing of the pancreatic stump. The CLASP technique is an effective and safe alternative technique to the current traditional methods of pancreatic stump closure.

Comparison of laparoscopic versus open distal pancreatectomy for benign, pre-malignant, and low grade malignant pancreatic tumors.

Backgrounds/AimsThe purpose of this study is to demonstrate that laparoscopic distal pancreatectomy in benign disease is is safer and more favorable to patients than open distal pancreatectomy.MethodsWe retrospectively reviewed data of 150 patients who underwent laparoscopic (n=69) or open (=81) distal pancreatectomy at a double institutes from 2008 to 2018. We reviewed each patient's history for age, sex, pathologic diagnosis. Specific outcomes that were included hospital stay, operative time (in minutes), operative blood loss (in milliliters), 30-daymajormorbidity and mortality (Clavian-Dindo classification), pancreatic leak rate (grade of leak A, B, or C), pancreatic hemorrhage.ResultsFrom 2008 to 2018, there were 150 patients underwent distal pancreatectomy with or without splenectomy for benign pancreatic disease. 81 patients underwent open and 69 patients underwent laparoscopic distal pancreatectomy (LDP) Intra-operative estimated blood loss was significantly lower in the LDP group than in the OPD group (200 vs. 400 ml p<0.01). There was no difference in blood transfusion between the two groups. There was a significant difference in the resection method between the two groups (p<0.01) and there was a significant difference in the use of mesh for prevention of postoperative pancreatic fistula (POPF) (53 vs. 34 p<0.01). There was no significant difference in incidence of POPF (15.9% in LDP vs 7.4% in ODP, p=0.235) between the two groups, morbidity rate between the two groups (18 vs. 30 p=0.152), post - pancreatectomy hemorrhage, wound infection, hospital stay and readmission.ConclusionsLDP showed there was no difference in the occurrence of POPF, complication and hospital stay. In contrast, intra-operative blood loss was significantly lower in the LDP group than in the ODP group, and LDP was also significantly better in the view point of the feeding advance. In other words, LDP is safer and more favorable to patients than ODP.

Defining high volume center for minimally invasive distal pancreatectomy

Presenter: Roheena Panni MD, MPHS | Washington University, St. Louis Background: Minimally Invasive Distal Pancreatectomy (MIDP) is associated with reduced intra-operative blood loss, transfusion requirement, and shorter length of stay compared to open distal pancreatectomy (ODP). However, its advantages over OPD and oncologic adequacy are unclear, due to the small number of centers performing MIDP and strict patient selection criteria. Several studies have outlined the relationship between hospital volume and postoperative mortality for patients undergoing pancreatic surgery, but the exact effect of centralization of care for MIDP still needs to be determined. The purpose of this study is to evaluate the association between hospital procedure volume and mortality for patients undergoing MIDP using a large database to determine an evidence-based threshold of hospital volume associated with improvement in mortality. Methods: Patients who underwent MIDP were identified using the National Cancer Database from 2010 to 2015. The relationship between hospital volume and 90-day mortality was assessed using a logistic regression model. Logistic regression analysis and restricted cubic spline regression analysis was performed to determine the linear and non-linear association between mean hospital volume and mean 90-day mortality. Results: 2,837 patients underwent distal pancreatectomy at 487 different hospitals. 30- and 90-day mortality of the study population were 1.27% (n=36) and 2.54% (n=72), respectively. Baseline characteristics and mean annual mortality of individual hospitals were determined (fig1). A logistic regression analysis was performed, which demonstrated that institutional volume is significantly associated with decreased overall 90-day mortality. The maximum improvement in 90-day mortality is seen if the annual hospital volume was greater than 7 (p<0.0001). We further explored the non-linear association between institutional volume and 90-day mortality, which demonstrated continued improvement in 90-day mortality with an increase in average hospital volume. Conclusion: Our data suggest that the centralization of MIDP is associated with lower postoperative mortality. Based on the results, we recommend defining a high volume center as hospitals performing eight or more MIDP cases per year. The true impact of this finding on overall survival should be assessed in future studies using large databases with long-term follow-up information.

Cost-effectiveness, cost-utility, and disease-specific quality of life in minimally invasive versus open distal pancreatectomy in the LEOPARD trial

Cost-effectiveness, cost-utility, and disease-specific quality of life in minimally invasive versus open distal pancreatectomy in the LEOPARD trial

Development and implementation of laparoscopic distal pancreatectomy in the United Kingdom: Indications, outcome and learning curve of 570 patients

Background: Laparoscopic distal pancreatectomy (LDP) is increasingly performed due to favourable perioperative outcomes. Nevertheless, data on the development of LDP on a nationwide level is lacking. This study investigated the development and learning curve of LDP in the United Kingdom (UK). Methods: A retrospective study of patients undergoing LDP from 2006 to 2016 in eleven tertiary referral centres in the UK was performed. Development of indication and perioperative outcome was examined by differences in trends over time periods (2006-2009, 2010-2013, 2014-2016). For learning curve analysis, the first 15 LDP cases performed of each centre were combined and compared to the subsequent cases. Results: In total, 570 LDP's were included. Median operating time was 240 min (IQR 182-300) with a median blood loss 200 mL (IQR 100-350). The conversion rate to open distal pancreatectomy was 12%) (n = 69). Majority of tumours were neuro-endocrine tumours (n = 152 [27%]), mucinous cystic neoplasm (n = 112 [20%]) and pancreatic ductal adenocarcinoma (n = 86 [15%]). Concomitant splenectomy was performed for 385 (68%) cases. Complications occurred in 49% (n = 276) of patients. The incidence of Pancreatic Fistula grade (POPF) B/C was 15% (n = 87). 26 (5%) patients required a reoperation. 90-day mortality occurred in 8 (1,4%). Total length of hospital stay was 6 days (IQR 5 to 8 days). LDP gained popularity over time and was more frequently used for PDAC [7% (n = 5) vs 19% (n = 47); P = 0.005]. Learning curve analysis showed improvement of estimated blood loss, rate of blood transfusions, complication rate (including POPF) and length of stay after the first 30 patients. Conclusion: Laparoscopic distal pancreatectomy is increasingly considered as a useful technique for lesions of the distal pancreas, included PDAC. Clear improvements of perioperative outcomes were found with expanding experience in LPD.

Outcomes of Elective and Emergency Conversion in Minimally Invasive Distal Pancreatectomy for Pancreatic Ductal Adenocarcinoma: An International Multicenter Propensity Score-matched Study.

The aim of this study was to investigate the impact of conversion during minimally invasive distal pancreatectomy (MIDP) for pancreatic ductal adenocarcinoma (PDAC) on outcome by a propensity-matched comparison with open distal pancreatectomy (ODP). MIDP is associated with faster recovery as compared with ODP. The high conversion rate (15%-25%) in patients with PDAC, however, is worrisome and may negatively influence outcome. A post hoc analysis of a retrospective cohort including distal pancreatectomies for PDAC from 34 centers in 11 countries. Patients requiring conversion were matched, using propensity scores, to ODP procedures (1:2 ratio). Indications for conversion were classified as elective conversions (eg, vascular involvement) or emergency conversions (eg, bleeding). Among 1212 distal pancreatectomies for PDAC, 345 patients underwent MIDP, with 68 (19.7%) conversions, mostly elective (n = 46, 67.6%). Vascular resection (other than splenic vessels) was required in 19.1% of the converted procedures. After matching (61 MIDP-converted vs 122 ODP), conversion did not affect R-status, recurrence of cancer, nor overall survival. However, emergency conversion was associated with increased overall morbidity (61.9% vs 31.1%, P= 0.007) and a trend to worse oncological outcome compared with ODP. Elective conversion was associated with comparable overall morbidity. Elective conversion in MIDP for PDAC was associated with comparable short-term and oncological outcomes in comparison with ODP. However, emergency conversions were associated with worse both short- and long-term outcomes, and should be prevented by careful patient selection, awareness of surgeons' learning curve, and consideration of early conversion when unexpected intraoperative findings are encountered.

Nesidioblastosis in an Adult with Short Gut Syndrome and Type 2 Diabetes

Adult nesidioblastosis is characterized by endogenous hyperinsulinemia typically causing post-prandial hypoglycemia, and most commonly occurs post-Roux-en-Y gastric bypass. We report a unique case of nesidioblastosis occurring in a 67-year-old female. A 5-year history of symptomatic hypoglycemia occurred in a patient with short bowel syndrome and type 2 diabetes mellitus (T2DM) managed previously with a glucagon-like peptide 1 (GLP-1) agonist, which achieved significant weight loss. Continuous glucose monitoring captured 42 hypoglycemia episodes in a 2-week period, and following an oral glucose tolerance test there was the suggestion of a hyperinsulinemia state. She was managed with an open distal pancreatectomy, and subsequently required medical therapy to maintain euglycemia. We present the first case of nesidioblastosis occurring in a patient with short bowel syndrome, pre-existing T2DM managed with a GLP-1 agonist which achieved significant weight loss, all of which we speculate could have predisposed to hypoglycemia and development of nesidioblastosis.

PSU7 THE DUTCH REFERENCE PRICE FOR INPATIENT DAYS SHOULD BE USED WITH SOME CAUTION

The Dutch guideline for economic evaluations in healthcare provides a reference price for an inpatient day. However, this price is based on an unpublished micro-costing study taking into account the costs of only three hospital units, that is neurology-, paediatric- and surgery unit. We aim to construct a reference price based on all hospital units and assess the impact of this modified reference price on the incremental cost utility ratio (ICUR) of minimally invasive pancreatectomy. We used UK tariffs of inpatients days to compare the average price of an inpatient day at the three hospital units examined in the unpublished Dutch micro-costing study with the average price of an inpatient day at all hospital units. The deviation in inpatient day price of the three units relative to all hospital units was used to convert the Dutch reference price to a modified average overall price. The ICUR of minimally invasive pancreatectomy compared with open distal pancreatectomy was re-estimated using the modified reference price and a sensitivity analysis was performed using the bounds of the 95% CI. The average price of the inpatient day of the three units compared to the overall average showed a deviation of +34.09%. Adjustment of the current reference price would change the inpatient day price from €476 to €355 (95%CI: €275-€615). The modified reference price increases the ICUR from -€23,722 to €4,980 per QALY (sensitivity analysis: -€20,969 - €13,015 per QALY). Our study suggests that the current Dutch reference price is an overestimation that can have a substantial impact on outcomes of economic evaluations. In addition, when performing sensitivity analyses the range applied for the cost of the inpatient day should be set rather wide to account for the variation in the price of inpatient days across hospital units.

International Validation of Reduced Major Morbidity After Minimally Invasive Distal Pancreatectomy Compared With Open Pancreatectomy.

To quantify the nationwide impact of minimally invasive distal pancreatectomy (MIDP) on major morbidity as compared with open distal pancreatectomy (ODP). A recent randomized controlled trial (RCT) demonstrated significant reduction in time to functional recovery after MIDP compared with ODP, but was not powered to assess potential risk reductions in major morbidity. International cohort study using the American College of Surgeons' National Quality Improvement Program (ACS-NSQIP) (88 centers; 2014-2016) to evaluate the association between surgical approach (MIDP vs ODP) and 30-day composite major morbidity (CMM; death or severe complications) with external model validation using Dutch Pancreatic Cancer Group data (17 centers; 2005-2016). Multivariable logistic regression assessed the impact of nationwide MIDP rates between 0% and 100% on postoperative CMM at conversion rates between 0% and 25%, using estimated marginal effects. A sensitivity analysis tested the impact at various scenarios and patient populations. Of 2921 ACS-NSQIP patients, 1562 (53%) underwent MIDP with 18% conversion, and 1359 (47%) underwent ODP. MIDP was independently associated with reduced CMM [odds ratio (OR) 0.50, 95% confidence interval (CI) 0.42-0.60, P < 0.001], confirmed by external model validation (n = 637, P < 0.003). The association between rising MIDP implementation rates and falling postoperative morbidity was linear between 0% (all ODP) and 100% (all MIDP). The absolute risk reduction for CMM was 11% (95% CI 7.3%-15%) at observed conversion rates and improved to 14% (95% CI 11%-18%) as conversion approached 0%. Similar effects were seen across subgroups. This international study predicted a nationwide 11% risk reduction for CMM after MIDP versus ODP, which is likely to improve as conversion rates decrease. These findings confirm secondary outcomes of the recent LEOPARD RCT.

Transpancreatic mattress suture with Vicryl mesh around the stump decreases postoperative pancreatic fistula after distal pancreatectomy

Postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP) remains the most common surgical complication. We have developed a novel stump closure technique after DP using transpancreatic mattress suture with Vicryl mesh (TMV) and reported our initial findings. The purpose of this study is to evaluate the efficacy of TMV compared to the conventional handsewn stump closure technique (CHS). This retrospective single-center study included 165 consecutive patients who underwent open DP from January 2010 to May 2018. Of these, 71 patients underwent DP using TMV after September 2014 and 94 patients underwent DP with CHS. The surgical outcomes were compared between the two groups. Clinically relevant POPF rate in the TMV group was significantly lower than that in the CHS group (5.6% vs. 17.2%, P=0.027). Morbidity rate was higher in the CHS group than that in the TMV group (16.9% vs. 27.7%, P=0.104). In the multivariate analysis, absence of additional organ resection (OR 3.57; 95% CI 1.18-10.43; P=0.025) and TMV (OR 0.24; 95% CI 0.07-0.73; P=0.010) were identified as independent preventing factors for clinically relevant POPF. TMV can be an effective stump closure technique for preventing POPF after DP.

Response: Oncologic outcomes of minimally invasive vs open distal pancreatectomy for pancreatic neuroendocrine tumors: Randomized controlled trials are needed

Response: Oncologic outcomes of minimally invasive vs open distal pancreatectomy for pancreatic neuroendocrine tumors: Randomized controlled trials are needed

Increasing evidence for minimally invasive approach to distal pancreatectomy

We read with great interest the work of Matsumoto et al., “ Laparoscopic versus open distal pancreatectomy for benign and low-grade malignant lesions of the pancreas: a single-center comparative study ” that was published in Surgery Today (1). This article describes a retrospective comparison of laparoscopic distal pancreatectomies (LDP) vs . open distal pancreatectomies (ODP) from a prospectively maintained database, performed in a single centre in Osaka, Japan. Consecutive patients (n=67) operated during a little over a 5-year period were included.

Robotic vs. laparoscopic distal pancreatectomy—equipoise in current clinical practice?

Since the first reports of minimally invasive distal pancreatectomy 25 years ago (1), widespread adoption into routine clinical practice has been slow (2), largely due to limited formal training opportunities, concerns surrounding oncological safety and the lack of randomised controlled trial data (3). The recent pan-European Minimally Invasive versus Open Distal Pancreatectomy for Ductal Adenocarcinoma (DIPLOMA) study incorporated 1,212 patients from 34 centres with a propensity-matched study design to demonstrate comparable survival and post-operative complication rates between the minimally-invasive vs . open groups (4). However, oncological outcome parameters were contradictory (with a minimally-invasive approach associated with higher R0 resection rates, but lower Gerota’s fascia resection and lymph node yields), strengthening the case for high quality randomised controlled trials in this setting (5). Further, of the 356 minimally invasive distal pancreatectomies included in the DIPLOMA study, only 16 (4%) were performed robotically. Robust evidence to support the theoretical benefits of robotic assistance in facilitating a safe and effective minimally invasive approach to distal pancreatectomy is currently lacking.

Laparoscopic versus open distal pancreatectomy (LAPOP): study protocol for a single center, nonblinded, randomized controlled trial

BackgroundEarlier nonrandomized studies have suggested that laparoscopic distal pancreatectomy (LDP) is advantageous compared with open distal pancreatectomy (ODP) regarding hospital stay, blood loss, and recovery. Only one randomized study has been conducted showing reduced time to functional recovery after LDP compared with ODP.MethodsLAPOP is a prospective randomized, nonblinded, parallel-group, single-center superiority trial. Sixty patients with lesions in the pancreatic body or tail that are found by a multidisciplinary tumor board to need surgical resection will be randomized to receive LDP or ODP. The primary outcome variable is postoperative hospital stay, and secondary outcomes include functional recovery (defined as no need for intravenous medications or fluids and as the ability of an ambulatory patient to perform activities of daily life), perioperative bleeding, complications, need for pain medication, and quality of life comparison.DiscussionThe LAPOP trial will test the hypothesis that LDP reduces postoperative hospital stay compared with ODP.Trial registrationISRCTN, 26912858. Registered on 28 September 2015.

The laparoscopic approach to distal pancreatectomy is a value-added proposition for patients undergoing care in moderate-volume and high-volume centers

BackgroundLittle is known regarding the impact of the minimally invasive approach to distal pancreatectomy on the aggregate costs of care for patients undergoing distal pancreatectomy. MethodsWe queried the Healthcare Cost and Utilization Project State Inpatient Database to identify patients undergoing elective laparoscopic distal pancreatectomy or open distal pancreatectomy between 2012 and 2014. Multivariable regression was used to evaluate postoperative outcomes including readmissions to 90 days after distal pancreatectomy. ResultsA total of 267 (11%) patients underwent laparoscopic distal pancreatectomy, and a total of 2,214 (89%) underwent open distal pancreatectomy. On multivariable regression, patients undergoing laparoscopic distal pancreatectomy had a decreased odds risk of having any severe adverse outcome (odds ratio 0.73, 95% confidence interval [0.54–0.97]), prolonged length of stay (odds ratio 0.49, 95% confidence interval [0.30–0.79]), and of being in the highest quartile for aggregate costs of care (odds ratio 0.46, 95% confidence interval [0.32–0.66]) relative to those undergoing open distal pancreatectomy. Patients undergoing laparoscopic distal pancreatectomy had a lower average 90-day aggregate cost of care than those undergoing open distal pancreatectomy when procedures were performed in high-volume (–$16,153, 95% CI: [–$23,342 to –$8,964]) centers. ConclusionPatients undergoing laparoscopic distal pancreatectomy have a lower risk of severe adverse outcomes, prolonged overall length of stay, and lower associated costs of care relative to those undergoing open distal pancreatectomy. This association is independent of hospital volume.

Perioperative hydrocortisone treatment reduces postoperative pancreatic fistula rate after open distal pancreatectomy. A randomized placebo-controlled trial

BackgroundPostoperative pancreatic fistula (POPF) is the most common complication after distal pancreatectomy (DP). In a recent RCT on pancreaticoduodenectomy (PD), perioperative hydrocortisone (HC) treatment reduced Clavien-Dindo (C-D) III-V complications. The aim of this study was to investigate whether perioperative HC treatment reduces the overall complications and clinically significant POPF after distal pancreatectomy (DP). MethodsFourty consecutive patients undergoing DP were randomized to receive intravenous HC 100mg/placebo every eight hours until the second postoperative day. Thirty-one patients were completed with DP and received HC/placebo every 8 h for two days postoperatively. The primary endpoint was overall complications (C-D III-V) and the secondary endpoint was the development of clinically significant POPF. ResultsPancreatic duct diameter, operative time and blood loss were similar in the groups. Ninety-day mortality was zero. With HC treatment the rates of C-D III-V complications tended to be lower compared to the placebo group (5.9% vs 21.4%, p = 0.034). The rate of grade B/C POPF was significantly reduced with HC treatment compared to the placebo group (5.9% vs. 42.9%, p = 0.028). ConclusionPerioperative HC treatment may have a favourable effect on overall major complications after open DP. HC treatment reduces the incidence of clinically significant POPF after open DP.

Epidural Analgesia Improves Postoperative Pain Control but Impedes Early Discharge in Patients Undergoing Pancreatic Surgery.

The aim of this study was to evaluate the impact of epidural analgesia (EA) on postoperative length of stay (LOS), expeditious discharge, and pain relief after pancreaticoduodenectomy (PD) and distal pancreatectomy (DP). Retrospective reviews of 2014-2015 American College of Surgeons National Surgical Quality Improvement Program databases and our institutional pancreatic surgery database were conducted. On univariate analysis, EA was associated with statistically significant longer lengths of stay for both PD and DP. On comparative analysis at mode LOS, discharged before versus after 7 days for PD and 6 days for DP, EA was a significant predictor for the longer groups for both procedures on multivariable analysis (PD, odds ratio of 1.465, P < 0.001; DP, odds ratio of 1.471, P = 0.004). On review of our institution's pancreatic surgery database, patient-reported pain scores were significantly lower in the EA groups than intravenous narcotics groups on the day of surgery only for both PD and DP. Epidural analgesia was associated with longer LOS with a most pronounced effect on early discharge after surgery for patients undergoing open PD and DP. It only resulted in superior pain control on the day of surgery.