Outcomes Of Pancreatoduodenectomy Research Articles

The impact of preoperative nutritional status on postoperative outcomes: an insight from Geriatric Nutritional Risk Index in elderly pancreaticoduodenectomy patients

BackgroundMalnutrition is not uncommon among the elderly undergoing pancreatoduodenectomy (PD) and is related to increased complications. Previous studies have shown that the Geriatric Nutritional Risk Index (GNRI) predicts outcomes in various populations. Nevertheless, the research exploring the correlation between GNRI and postoperative outcomes in PD is scarce. This study aimed to investigate the preoperative malnutrition, as measured by GNRI, on outcomes in elderly patients undergoing PD.Materials and MethodsThis retrospective analysis enrolled 144 elderly patients underwent PD for periampullary tumors from November 2016 to December 2021. Patients were stratified based on the GNRI value: high/moderate nutrition risk (GNRI ≤ 92, N = 54), low nutrition risk (92 < GNRI ≤ 98, N = 35), and no nutrition risk (GNRI > 98, N = 55). Perioperative outcomes and postoperative surgical complications were compared between these groups. Univariate and multivariate analyses were performed on major postoperative complications and prolonged postoperative length of stay (PLOS).ResultsPatients in the high/moderate risk group were significantly older, with lower BMI (P = 0.012), higher mortality rate (11.1%, P = 0.024), longer PLOS (P < 0.001), and higher incidence of over grade IIIB complications (37.0%, P = 0.001), Univariate and multivariate analyses showed the high/moderate risk GNRI group (OR 3.61, P = 0.032), increased age (OR 1.11, P = 0.014) and operative time over 8 h (OR 3.04, P = 0.027) were significantly associated with increased major postoperative complications. The high/moderate risk GNRI group was also a significant predictor for prolonged PLOS (OR 3.91, P = 0.002).ConclusionsPreoperative GNRI has the potential to be a predictive tool for identifying high-risk elderly patients and monitoring nutritional status preoperatively to improve postoperative surgical outcomes following PD.

Completion pancreatectomy during pancreatoduodenectomy: A lifesaving solution in high-risk patients.

Postoperative pancreatic fistula (POPF) is responsible of most major complications and fatalities after PD. By avoiding POPF, TP may improve operative outcomes in high-risk patients. The aim was to compare total pancreatectomy (TP) and pancreatoduodenectomy (PD) in high-risk patients and evaluate results of implementing a risk-tailored strategy in clinical practice. Between 2014 and 2023, 139 patients (76 men, median age 67years) underwent resection of disease located in the head of the pancreas. Starting January 1, 2022, we offered TP to patients at high POPF risks (fistula risk score (FRS) ≥7) and to patients with intermediate POPF risks (FRS: 3-6) and high risks of failure to rescue (age> 75years, ASA score ≥3). We compared outcomes of TP and PD and evaluated the results of the new strategy implementation on operative outcomes. Propensity score-based analysis was performed to limit bias of between-group comparison. Eventually, 26 (19%) patients underwent TP and 113 (81%) patients underwent PD. Severe complications occurred in 42 (30%) patients and 13 (9%) patients died. TP resulted in shorter lengths of hospital stay (median: 14days [11; 18] vs. 17days [13; 24], p=0.016) and less risks of post-pancreatectomy hemorrhage (PPH) (0% vs. 20%, p<0.001) compared to PD. Crude and propensity match analysis showed that the implementation of a risk-tailored strategy led to significant reduction of reoperation, POPF, PPH and mortality rates. The use of TP as part of a risk-tailored strategy in high-risk patients can be lifesaving.

Nationwide Outcome after Pancreatoduodenectomy in Patients at very High Risk (ISGPS-D) for Postoperative Pancreatic Fistula.

To assess nationwide surgical outcome after pancreatoduodenectomy (PD) in patients at very high risk for postoperative pancreatic fistula (POPF), categorized as ISGPS-D. Morbidity and mortality after ISGPS-D PD is perceived so high that a recent randomized trial advocated prophylactic total pancreatectomy (TP) as alternative aiming to lower this risk. However, current outcomes of ISGPS-D PD remain unknown as large nationwide series are lacking. Nationwide retrospective analysis including consecutive patients undergoing ISGPS-D PD (i.e., soft texture and pancreatic duct ≤3 mm), using the mandatory Dutch Pancreatic Cancer Audit (2014-2021). Primary outcome was in-hospital mortality and secondary outcomes included major morbidity (i.e., Clavien-Dindo grade ≥IIIa) and POPF (ISGPS grade B/C). The use of prophylactic TP to avoid POPF during the study period was assessed. Overall, 1402 patients were included. In-hospital mortality was 4.1% (n=57), which decreased to 3.7% (n=20/536) in the last 2 years. Major morbidity occurred in 642 patients (45.9%) and POPF in 410 (30.0%), which corresponded with failure to rescue in 8.9% (n=57/642). Patients with POPF had increased rates of major morbidity (88.0% vs. 28.3%; P<0.001) and mortality (6.3% vs. 3.5%; P=0.016), compared to patients without POPF. Among 190 patients undergoing TP, prophylactic TP to prevent POPF was performed in 4 (2.1%). This nationwide series found a 4.1% in-hospital mortality after ISGPS-D PD with 45.9% major morbidity, leaving little room for improvement through prophylactic TP. Nevertheless, given the outcomes in 30% of patients who develop POPF, future randomized trials should aim to prevent and mitigate POPF in this high-risk category.

HPB P17 Preoperative cardiovascular disease and outcomes ofpancreatoduodenectomy performed for malignancy

Abstract Background Despite improvements to morbidity and mortality rates in recent decades, pancreatoduodenectomy (PD) remains a high-risk operation. Patients with pre-existing cardiovascular disease (CVD) are known to be at increased risk of perioperative morbidity and mortality. Evidence is lacking on the impact of CVD on long-term outcomes. This study aimed to compare the outcomes of PD patients with preoperative CVD to those without. Methods Data was extracted from the Recurrence After Whipple’s (RAW) study, a multicentre retrospective cohort study of outcomes of PD performed for pancreatic head malignancy (29 centres in 8 countries, n=1484). Pre-existing CVD included any of the following: hypertension (HTN), atrial fibrillation (AF), other cardiac arrhythmia, ischaemic heart disease (IHD), previous cardiovascular surgery, heart failure, peripheral vascular disease (PVD), previous stroke, previous transient ischaemic attack (TIA), pulmonary HTN, deep vein thrombosis, valve disease, cardiomyopathy, subarachnoid haemorrhage, peri-/myocarditis and myocardial infarction. Several outcomes were compared: length of stay, 30-day readmission, 90-day mortality, unplanned return to theatre rate, and five-year survival. Results From 1484 cases, 590 patients (39.8%) had pre-existing CVD. HTN, AF, other cardiac arrhythmia, IHD, previous cardiovascular surgery, heart failure and PVD affected 33.0%, 3.6%, 1.0%, 5.3%, 1.9%, 1.3% and 1.5% of patients, respectively. Remaining pathologies surmounted to &amp;lt;1%. 30-day readmission (10.5% vs 8.1%, p=0.1), 90-day mortality (4.4% vs 3.2%, p=0.3), unplanned return to theatre (5.2% vs 4.8%, p=0.7) and five-year survival (31.2% vs 32.1%, p=0.7) were similar between the patient groups, however, median LoS was significantly longer in those with CVD (14 vs 12 days, p&amp;lt;0.0001). Similar results were obtained when hypertension was not classified as a cardiovascular comorbidity. Conclusions In our multicentre study of PD outcomes, patients with a preoperative cardiovascular comorbidity had longer length of stay than those who did not but the other studied outcomes were unaffected.

OGC P02 Neutrophil/lymphocyte ratio and long-term survival after pancreatoduodenectomy for malignancy

Abstract Background Previous authors have highlighted that preoperative neutrophil/lymphocyte ratio (NLR) may be of prognostic importance in patients who undergo pancreatoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC), ampullary carcinoma (AA) or cholangiocarcinoma (CC) of the pancreatic head/periampullary region. Various cut-off thresholds have been suggested. This study aimed to compare the five-year survival rates of PD patients with high preoperative NLR to those with low preoperative NLR (using thresholds from recent studies). Methods Data was extracted from the Recurrence After Whipple’s (RAW) study, a multicentre retrospective cohort study of outcomes of PD performed for pancreatic head malignancy (29 centres in 8 countries, n=1484). Patients were grouped by their underlying cancer type and divided into “high NLR” (PDAC: ≥ 3.74, AA: ≥3.0, CC: ≥2.75) and “low NLR” (PDAC: &amp;lt;3.74, AA: &amp;lt;3.0, CC: &amp;lt;2.75) groups. Five-year survival rates were compared using Fisher’s exact test. Results Out of 1484 patients, 885 (59.6%) had PDAC, 394 (26.5%) had AA and 205 (13.8%) had CC, and NLR was available in 88.4%, 89.1% and 92.2% of cases, respectively. The median NLR was 2.7 (range: 0.1-34.0), 2.8 (range: 0.3-103.0) and 2.7 (range:0.1-83.3) for patients with PDAC, AA and CC, respectively. Low NLR did not correlate with improved five-year survival rates in any of the studied cancers (PDAC: 24.5% vs 23.8%, p=0.9, AA: 56.1% vs 51.2%, p=0.4, CC: 34.4% vs 25.8%, p=0.2). Conclusions In our multicentre study of PD outcomes, preoperative NLR was not useful for predicting five-year survival in patients with PDAC, AA or CC.

HPB P16 How relevant are additional histological features when predicting five-year recurrence/survival rates afterpancreatoduodenectomy for ampullary adenocarcinoma? Results from the Recurrence After Whipple’s (RAW) study

Abstract Background Providing they have an appropriate performance status, patients with ampullary adenocarcinoma (AA) may be offered pancreatoduodenectomy (PD) with curative intent. Aggressive histological tumour characteristics are known to correlate with poor long-term outcomes. This study aimed to quantify how peripancreatic fact invasion (PPFI), perineural invasion (PNI), microvascular invasion (MVI) and lymphatic invasion (LI) correlate with five-year recurrence and five-year survivalrates. Methods Data were extracted from the Recurrence After Whipple’s (RAW) study, a multicentre retrospective cohort study of outcomes of PD performed for pancreatic head malignancy (29 centres in 8 countries, n=1484). Patients with histologically confirmed AA were identified and compared by their PPFI, PNI, MVI and LI statuses. Fisher’s exact test was used for the comparisons. Results A total of 394 patients (26.5%) had AA confirmed. Incidence rates of PPFI, PNI, MVI and LI were 37.8%, 46.1%, 45.2% and 58.6%, respectively. Five-year recurrence was significantly higher in patients demonstrating PPFI (58.9% vs 34.3%, p=0.0005), PNI (56.6% vs 34.0%, p=0.0001), MVI (60.2% vs 34.2%, p&amp;lt;0.0001) and LI (54.7% vs29.2%, p&amp;lt;0.00001). Five-year survival was significantly lower in patients with PPFI (29.4% vs 62.9%, p&amp;lt;0.0001), PNI (40.4% vs 64.8%, p&amp;lt;0.0001), MVI (43.0% vs 61.3%, p=0.003) and LI (44.1% vs 65.0%, p&amp;lt;0.0005). Patients with PPFI, PNI, MVI and LI were significantly more likely to have histological T3-4 disease (vsT1-2, all p&amp;lt;0.0001). Conclusions In our multicentre study of AA patients who underwent PD, less than half had histological evidence of PPFI, PNI or MVI, but a majority had LI. All of these features were associated with increased recurrence and reduced survival rates. However, this likely reflects the fact that these features all correlate with more advanced histological disease.

SP2.7 Is routine nasogastric tube placement following pancreatoduodenectomy really necessary?

Abstract Background Traditionally, pancreatoduodenectomy (PD) patients would leave theatre with a nasogastric tube (NGT) in situ. Recent evidence has suggested that the potential drawbacks of routine placement may outweigh the potential gains. This study aimed to compare the outcomes of PD patients who received a NGT intra-operatively to those did not. Methods Data taken from Recurrence After Whipple’s (RAW) study, a multicentre retrospective cohort study of outcomes of PD performed for pancreatic head malignancy (29 centres from 8 countries, n=1484). The following outcome measures were used: median length of stay (LoS), incidence of delayed gastric emptying (DGE), incidence of grade B/C DGE, and the provision of postoperative nutritional support. Analyses were performed using Fisher’s exact test and the Mann-Whitney U test. Results Out of 1484 patients who underwent PD for malignancy, 1098 (74.0%) had data on their NGT status. 91.6% of patients received an intra-operative NGT. The median length of time until tube removal was four days (range: 1-64, interquartile range: 3). in comparison to the group with no NG tube, median length of stay (both 14 days, p=0.9), as well as incidence of DGE (14.3% vs 7.6%, p=0.08) grade B/C DGE (8.3% vs 4.3%, p=0.2) were similar. Patients who did not receive a tube less often received postoperative nutritional support (any form, 30.4% vs 49.8%, p=0.0004). Conclusion Most patients underwent PD had NG placed intraoperatively. Had no affect length of stay or incidence of DGE. Patients who received a NGT more often received postoperative nutritional support. NGTs should only be placed when they are clinically indicated.

SP2.6 Histological TNM stage and five-year survival after pancreatoduodenectomy for pancreatic ductal adenocarcinoma

Abstract Aims Patients with a pancreatic ductal adenocarcinoma (PDAC) of the pancreatic head may be offered pancreatoduodenectomy (PD) providing they are suitable candidates. Unfortunately, recurrence rates are high following this operation and few patients achieve long-term survival. This study aimed to investigate and quantify the relationship between histological tumour, node and metastasis stage, and five-year survival. Methods Data were extracted from the Recurrence After Whipple’s (RAW) study, a multicentre retrospective cohort study of outcomes of PD performed for malignancy (29 centres from 8 countries, n=1484). PDAC patients were grouped by their T stage, N stage and M stage, and five-year survival rates were compared using Fisher’s exact test. Results A total of 885 patients (59.6%) had PDAC confirmed histologically. Five-year survival was 57.4%, 46.0%, 17.0% and 32.0% in patients with T1, T2, T3 and T4 disease, respectively (unavailable: 7 patients). T1-2 patients (vs T3-4) had significantly higher rates of five-year survival (OR: 4.8, 95% CI: 3.3-7.0). N0 patients (vs N1-2) had significantly higher rates of five-year survival (OR: 4.5, 95% CI: 3.2-6.3). M0 patients (vs M1) also had higher five-year survival rates but this was not quite significant due to the small sample size of the M1 group (OR: 3.8, 25.7% vs 8.3%, p=0.06). Conclusion In our multicentre study of patients who underwent PD for PDAC, increasing T and N histological stages were found to correlate with reduced five-year survival. The figures provided can be used to guide the consenting process and predict outcomes in individual patients.

Outcome of pancreatoduodenectomy with venous resection and reconstruction in locally advanced pancreatic head cancer

Outcome of pancreatoduodenectomy with venous resection and reconstruction in locally advanced pancreatic head cancer

P-P53 Textbook outcomes in pancreatoduodenectomy are improved in high volume specialist pancreas-only centres

Abstract Background Traditional single surgical quality indicators are commonly used however they are poor for assessing global outcomes for patients. Composite outcomes such as the ‘Textbook Outcome’ (TO) is a composite outcome to determine the success of the quality of the surgical process, and compare outcomes between institutions and patient groups, described by the Dutch Pancreatic Cancer Audit Group for Pancreatoduodenectomy (PD). They reported national TOs for PD of 58.3%, we compared this to TOs in a UK high volume specialist pancreas-only centre, Royal Stoke. Methods Patients who underwent PD from January 2017 to December 2020 were identified from our database. TO was defined as absence the following: post-operative pancreatic fistula (POPF) (grade B/C), post-pancreatectomy haemorrhage (PPH), bile leak, severe complications (Clavien Dindo grade III or more), 30-day readmission and 30-day mortality. Results 153 patients underwent PD during the 4-year study period. The median age was 71years (range 37-85 years), and there was a slight male preponderance (54.9%, 84/153). 47% had pancreatic ductal adenocarcinoma (72/153), 17% ampullary carcinoma (26/153), 9% cholangiocarcinoma (14/153), 9% duodenal carcinoma (14/153), and benign pathology included cases with IPMN and duodenal polyps with high grade dysplasia. There was a statistically significant difference in textbook outcome in our cohort compared to the Dutch Study (70.3%, 108/153 vs 58.3%, 895/1536; p=0.003086), with components of TO shown in Figure 1. Conclusions TO represent composite outcome for identifying good practice, areas for shared learning and areas for improvement. PD performed in high-volume pancreas-only specialist centers appear to have better outcomes following PD than lower-volume centres. Further investigation is required to assess why outcomes are different between centres, and identify how best practice can be shared.

Outcomes comparison of Pancreato-Gastrostomy and Isolated Jejunal Loop Pancreato-Jejunostomy following Pancreato-Duodenectomy in patients with soft pancreas and at moderate-high risk for POPF: a retrospective multicenter experience-based analysis.

Following pancreatoduodenectomy (PD), the modality of pancreato-enteric continuity restoration may impact on postoperative pancreatic fistula (POPF) risk. The aim of this study is to compare, among patients with soft pancreas and at moderate/high risk for POPF, the outcomes of PD with Pancreato-Gastrostomy (PG), versus Isolated Jejunal Loop Pancreato-Jejunostomy (IJL-PJ). 193 patients with a Callery Fistula Risk Score (C-FRS) ≥ 3 operated at 3 HPB Units, two performing PG and one IJL-PJ as their preferred anastomotic technique following PD (2009-2019) were included in this study (PG = 123, IJL-PJ = 70). Primary outcomes were POPF, clinically relevant (cr-)postoperative pancreatic hemorrhage (cr-PPH), delayed gastric emptying (cr-DGE), and postoperative major complications and mortality. POPF, cr-PPH, and cr-DGE occurred in 21.8%, 17.6%, and 11.4% of patients, and did not differ significantly between PG (26%, 19.5%, and 10.6%, respectively) and IJL-PJ (17.1%, 14.3%, and 12.9%, respectively; all p > 0.05) patients. Major (Dindo ≥ 3) complication and mortality rates were 26.4% and 3.3%, respectively, and did not differ significantly between PG (29.3% and 3.8%) and IJL-PJ (21.4% and 2.9) patients (p > 0.05). A faster surgical drain and nasogastric tube removal matched a significantly shorter hospitalization among IJL-PJ patients (median LOS: 18days versus 25days among PG patients, p < 0.001). In conclusion, IJL-PJ and PG, when performed by surgeons specialized with the concerned anastomotic technique in patients with soft pancreas and moderate/high risk for POPF, have similar results in terms of perioperative mortality and postoperative complications both overall and specific for PD.

Applying benchmark outcomes in pancreatoduodenectomy at a center in Chile

Introduction: Pancreatoduodenectomy (PD) is a high demanding technical procedure, with significant risks of morbidity and mortality. Surgical departments performing this operation around the world should aim for results that are within the best expected outcomes. The aim of this study is to compare our results in PD using the recently published tool for outcome comparisons Benchmarks in Pancreatic Surgery. A Novel Tool for Unbiased Outcome Comparisons. (Ann Surg, 2019 vol. 270 (2) pp. 211-218.) Methods: We reviewed all our PD performed from January 2015 to January 2020 in our institution and made a comparative table among patients within inclusion criteria and overall sample based on the paper proposal. Results: The overall sample is 38 patients, the patients within the benchmark inclusion criteria were 28, the comparative results are shown in table.PP04-138Benchmarks in PD in Clinica Santa MariaOutcome BenchmarksWithin inclusion criteria N=28Overall Sample N=38BenchmarkOperative Time (hours)6.5 (4.4-11)6.1 (4.4-11)<7:30LOS (Days)15.6 (10-53)16.1 (10-80)<15Overall complication53.8%52.4%<73%Clavien IV complication7.8%7.4%<5%Pancreatic Fistula B-C11%18%<19%In Hospital Mortality00<1.6%R1 status3.7%5.2%<39%Readmission18%13%<21%1 year DFS85%73%>53% Open table in a new tab Conclusions: The benchmark outcomes stablished in the mentioned paper are a novel and excellent tool to avoid biases at the moment to analyze results, specially in a low volume center as ours. In the other hand is an inspiring tool to reach and improve the outcomes of our patients.

Frailty score or comorbidity score: which is more predictive of outcomes in pancreatoduodenectomy

Frailty score or comorbidity score: which is more predictive of outcomes in pancreatoduodenectomy

Immediate outcomes of pancreatoduodenectomy after different digestive reconstruction procedures

To study the immediate results of pancreatoduodenectomy depending on digestive reconstruction procedure. We analyzed 242 patients who underwent pancreatoduodenectomy for the period from January 2013 to December 2019. There were 32 combined procedures: 28 (11.6%) with portal vein resection and 8 (3.3%) simultaneous operations (right-sided hemicolectomy - 4, right-sided adrenalectomy - 2, gastrectomy with splenectomy - 2). Pancreatic stump was inserted into the jejunum in 156 (64.5%) patients, into the stomach - in 86 (35.5%) cases. Postoperative period was uneventful in 180 (74.4%) patients. Eighty postoperative complications were observed in 62 (25.6%) patients; 221 (91.3%) patients were discharged, 21 (8.7%) patients died. Pancreatic necrosis was the most common postoperative event and provoked 65 (82.5%) various complications (38 (72.1%) in patients with pancreaticojejunostomy and 20 (71.5%) in those with pancreaticogastrostomy). Incidence of complications was similar in both groups. However, pancreaticojejunostomy was followed by severe pancreatic fistula type C in 12 (23.1%) patients, type B in 24 (46.1%) cases. In case of pancreaticogastrostomy, pancreatic fistula type C occurred in 4 (14.3%) cases, type B - in 8 (28.6%) patients. Pancreatic necrosis was the most common postoperative event after pancreatoduodenectomy. Fewer severe pancreatic fistulae (type C) were recorded after pancreaticogastrostomy although these patients had lower density of the pancreas and unclear pancreatic duct. Choice of pancreatic-digestive anastomosis should be determined by features of pancreatic parenchyma, pancreatic duct diameter. Nevertheless, final decision is a prerogative of surgeon. Pancreaticogastrostomy is especially advisable in minimally invasive PDEs that will simplify inclusion of the pancreas into digestive system and reduce the incidence of complications and mortality.

Emerging centers can provide textbook outcomes (TO) for Pancreatoduodenectomy (PD): a multicenter study from India

Introduction: Textbook Outcome has recently been introduced as novel quality measure for pancreatic surgery. Centralization is one of the strategies proposed in Western Europe and USA for providing quality outcomes following PD. With large populations and underdeveloped healthcare system, applicability of ´centralization´ for low-middle income countries (LMIC) such as India remains debatable. For LMIC the challenges are:-Rapid development of well equipped new centers to provide healthcare facilities closer to populations / decrease overwhelming workload of existing centers-Provide quality care at affordable costs We investigated whether TO for PD can be achieved at such ´emerging´ centers. Methods: Two surgeons trained at same institution from 2000 - 2005 set up independent centers for major digestive tract surgery in North & Western India. The outcomes of PD were retrospectively analyzed. Results: Eighty seven patients underwent PD (Team 1 - 39, 10 years; Team 2 - 48, 7 years). TO were achieved in 82.7% patients (Figure1). The median length of stay (postoperative) was 10days. In hospital or 30-day mortality was 2 (2.2%). Three (3.4%) patients had CR-POPF. The cost of treatment ranged from 6000 USD (uncomplicated) to 18,000 -20000 USD (complicated; Clavien-Dindo 4). The demographic, technical details and outcomes for the 2 groups are provided in Table 1. Conclusion: Well trained surgical teams at emerging centers in LMIC can achieve TO following PD. Development of new well equipped centers manned by adequately trained personnel is reasonable strategy for LMIC for providing quality care at affordable costs.PP04-078Demographic, technical details and outcomes of PDParameterTeam 1 (n=39)Team 2 (n=48)Total (n=87)Mean Age (range)55.8 (19-71)56.5 (26-78)Site: Pancreas / Ampulla / Bile duct / Duodenum09 / 17 / 07 / 0614 / 20 / 08 / 0623 / 37 / 15 / 12PJ details: Duct-mucosa / Dunking39 / 046 / 0285 / 02Outcomes: POPF (B & C) / Mortality03 / 020 / 003 / 02Hemorrhage020103Clavien-Dindo Grade: None / 1 / 2 / 3 / 4 / 511 / 05 / 15 / 04 / 02 / 0211 / 20 / 14 / 03 / 0 / 022 / 25 / 29 / 07 / 02 / 02Readmission (30 day)020507Bile leak010102Textbook Outcomes29 (74.4%)43 (89.6%)72 (82.7%) Open table in a new tab

The Influence of Intraoperative Blood Loss on Fistula Development Following Pancreatoduodenectomy.

To investigate the role of intraoperative estimated blood loss (EBL) on development of clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreatoduodenectomy (PD). Minimizing EBL has been shown to decrease transfusions and provide better perioperative outcomes in PD. EBL is also felt to be influential on CR-POPF development. This study consists of 5534 PDs from a 17-institution collaborative (2003-2018). EBL was progressively categorized (≤150mL; 151-400mL; 401-1,000 mL; > 1,000 mL). Impact of additive EBL was assessed using 20 3- factor fistula risk score (FRS) scenarios reflective of endogenous CR-POPF risk. CR-POPF developed in 13.6% of patients (N = 753) and median EBL was 400 mL (interquartile range 250-600 mL). CR-POPF and Grade C POPF were associated with elevated EBL (median 350 vs 400 mL, P = 0.002; 372 vs 500 mL, P < 0.001, respectively). Progressive EBL cohorts displayed incremental CR-POPF rates (8.5%, 13.4%, 15.2%, 16.9%; P < 0.001). EBL >400mL was associated with increased CR-POPF occurrence in 13/20 endogenous risk scenarios. Moreover, 8 of 10 scenarios predicated on a soft gland demonstrated increased CR-POPF incidence. Hypothetical projections demonstrate significant reductions in CR-POPF can be obtained with 1-, 2-, and 3-point decreases in FRS points attributed to EBL risk (12.2%, 17.4%, and 20.0%; P < 0.001). This is especially pronounced in high-risk (FRS7-10) patients, who demonstrate up to a 31% reduction (P < 0.001). Surgeons in the lowest-quartile of median EBL demonstrated CR-POPF rates less than half those in the upper-quartile (7.9% vs 18.8%; P < 0.001). EBL independently contributes significant biological risk to CR-POPF. Substantial reductions in CR-POPF occurrence are projected and obtainable by minimizing EBL. Decreased individual surgeon EBL is associated with improvements in CR-POPF.

Transatlantic registries of pancreatic surgery in the United States of America, Germany, the Netherlands, and Sweden: Comparing design, variables, patients, treatment strategies, and outcomes

BackgroundRegistries of pancreatic surgery have become increasingly popular as they facilitate both quality improvement and clinical research. We aimed to compare registries for design, variables collected, patient characteristics, treatment strategies, clinical outcomes, and pathology. MethodsRegistered variables and outcomes of pancreatoduodenectomy (2014–2017) in 4 nationwide or multicenter pancreatic surgery registries from the United States of America (American College of Surgeons National Surgical Quality Improvement Program), Germany (Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie - Studien-, Dokumentations- und Qualitätszentrum), the Netherlands (Dutch Pancreatic Cancer Audit), and Sweden (Swedish National Pancreatic and Periampullary Cancer Registry) were compared. A core registry set of 55 parameters was identified and evaluated using relative and absolute largest differences between extremes (smallest versus largest). ResultsOverall, 22,983 pancreatoduodenectomies were included (15,224, 3,558, 2,795, and 1,406 in the United States of America, Germany, the Netherlands, and Sweden). Design of the registries varied because 20 out of 55 (36.4%) core parameters were not available in 1 or more registries. Preoperative chemotherapy in patients with pancreatic ductal adenocarcinoma was administered in 27.6%, 4.9%, 7.0%, and 3.4% (relative largest difference 8.1, absolute largest difference 24.2%, P < .001). Minimally invasive surgery was performed in 7.8%, 4.5%, 13.5%, and unknown (relative largest difference 3.0, absolute largest difference 9.0%, P < .001). Median length of stay was 8.0, 16.0, 12.0, and 11.0 days (relative largest difference 2.0, absolute largest difference 8.0, P < .001). Reoperation was performed in 5.7%, 17.1%, 8.7%, and 11.2% (relative largest difference 3.0, absolute largest difference 11.4%, P < .001). In-hospital mortality was 1.3%, 4.7%, 3.6%, and 2.7% (relative largest difference 3.6, absolute largest difference 3.4%, P < .001). ConclusionConsiderable differences exist in the design, variables, patients, treatment strategies, and outcomes in 4 Western registries of pancreatic surgery. The absolute largest differences of 24.3% for the use of preoperative chemotherapy, 9.0% for minimally invasive surgery, 11.4% for reoperation rate, and 3.4% for in-hospital mortality require further study and improvement. This analysis provides 55 core parameters for pancreatic surgery registries.

Correlation between Intraoperative Fluid Administration and Outcomes of Pancreatoduodenectomy.

Background Intraoperative fluid (IOF) administration plays an important role during major abdominal surgery although increased fluid intake can adversely influence postoperative outcomes. However, the effect of the IOF rate on the outcomes of pancreatoduodenectomy (PD) is unclear. Methods 151 patients, who underwent PD at Binzhou Medical University Hospital between January 2010 and May 2017, were categorized into three groups according to IOF rates (ml/kg/hr): restricted (<10, n = 47), standard (10–15, n = 76), and liberal (>15, n = 28). Results The overall postoperative morbidity was 56.95%. The incidence of postoperative pancreatic fistula (POPF) was 11.26%. The in-hospital mortality rate was 7.28% with the most common cause being grade C POPF and secondary intra-abdominal infections. The patients in the liberal group had significantly higher incidences of POPF (25%) and respiratory complications (21.43%). The other outcome parameters such as recovery of bowel function, hospital stay, and postoperative daily drainage were similar among the groups. Multivariable analysis confirmed the IOF rate to be most strongly associated with POPF (odds ratio: 5.195, confidence interval: 1.142–23.823, P = 0.023) and respiratory complications (odds ratio: 7.302, confidence interval: 0.676–58.231, P = 0.025). Conclusions The IOF rate significantly affects the incidence of POPF and respiratory complications after PD. Careful patient-oriented fluid therapy may help to prevent these complications.

Impact of Age on Short- and Long-Term Outcomes after Pancreatoduodenectomy for Periampullary Neoplasms.

Background Although mortality and morbidity of pancreatoduodenectomy (PD) have improved significantly over the past years, the impact of age for patients undergoing PD is still debated. This study is aimed at analyzing short- and long-term outcomes of PD in elderly patients. Methods 124 consecutive patients who have undergone PD for pancreas neoplasms in our center between 2012 and 2017 were analyzed. Patients were divided into two groups: group I (<75 years) and group II (≥75 years). Demographic features and intraoperative and clinical-pathological data were collected. Primary endpoints were perioperative morbidity and mortality; complications were classified according to the Clavien-Dindo Score. Secondary endpoints included feasibility of adjuvant treatment and overall survival rates. Results A total of 106 patients were included in this study. There were 73 (68.9%) patients in group I and 33 (31.1%) in group II. Perioperative deceases were 4 (3.6%), and postoperative pancreatic fistulas were 34 (32.1%). Significant difference between two groups was demonstrated for the ASA Score (p = 0.004), Karnofsky Score (p = 0.025), preoperative jaundice (p = 0.004), and pulmonary complications (p = 0.034). No significance was shown for diabetes, radicality of resection, stage of disease, operative time, length of stay, postoperative complications according to the Clavien-Dindo Score, postoperative mortality, pancreatic fistula, and reoperation rates. 69.9% of the patients in group I underwent adjuvant treatment vs. 39.4% of the older ones (p = 0.012). Mean overall survival was 28.5 months in group I vs. 22 months in group II (p = 0.909). Conclusion PD can be performed safely in elderly patients. Advanced age should not be an absolute contraindication for PD, even if greater frailty should be considered. The outcome of elderly patients who have undergone PD is similar to that of younger patients, even though adjuvant treatment administration is significantly lower, demonstrating that surgery remains the main therapeutic option.

Learning curve for pancreatoduodenectomy: can it be generalized?

We hypothesized that a learning curve exists for pancreatoduodenectomy (PD) and that the factors that show a learning curve and the degree of improvement over time differ among surgeons. We analysed the outcomes of PD in 300 patients operated by two surgeons between 2001 and 2014; these comprised the first 150 patients operated by each surgeon. Patients operated by each surgeon were classified into three groups according to the chronological sequence of operation (50 patients per group). For surgeon A, the median operation time (496 versus 454 versus 418 min, P < 0.001) and the mean amount of red blood cell transfusion (3.76 versus 2.76 versus 1.26 packs, P < 0.001) showed a slight but progressive decrease from the first 50 cases to the second and the third 50 cases. For surgeon B, only the operation time, which decreased and ultimately plateaued at approximately case 100, was significantly different among the groups. There was no improvement in post-operative complications, re-operation rates, mortality, length of stay and re-admission rates over time for both surgeons. We demonstrated that a learning curve for PD exists with respect to various factors. However, the factors for which learning curves were exhibited and the degree of improvement over time were different between the two surgeons.