Impact of Complications After Pancreatoduodenectomy on Mortality, Organ Failure, Hospital Stay, and Readmission

Abstract

Objective: To quantify the impact of individual complications on mortality, organ failure, hospital stay, and readmission after pancreatoduodenectomy. Summary of Background Data: An initial complication may provoke a sequence of adverse events potentially leading to mortality after pancreatoduodenectomy. This study was conducted to aid prioritization of quality improvement initiatives.Methods: Data from consecutive patients undergoing pancreatoduodenectomy (2014-2017) were extracted from the Dutch Pancreatic Cancer Audit. Population attributable fractions (PAF) were calculated for the association of each complication (ie, postoperative pancreatic fistula, postpancreatectomy hemorrhage, bile leakage, delayed gastric emptying, wound infection, and pneumonia) with each unfavorable outcome [ie, in-hospital mortality, organ failure, prolonged hospital stay (>75th percentile), and unplanned readmission), whereas adjusting for confounders and other complications. The PAF represents the proportion of an outcome that could be prevented if a complication would be eliminated completely. Results: Overall, 2620 patients were analyzed. In-hospital mortality occurred in 95 patients (3.6%), organ failure in 198 patients (7.6%), and readmission in 427 patients (16.2%). Postoperative pancreatic fistula and postpancreatectomy hemorrhage had the greatest independent impact on mortality [PAF 25.7% (95% CI 13.4-37.9) and 32.8% (21.9-43.8), respectively] and organ failure [PAF 21.8% (95% CI 12.9-30.6) and 22.1% (15.0-29.1), respectively]. Delayed gastric emptying had the greatest independent impact on prolonged hospital stay ]. The impact of individual complications on unplanned readmission was smaller than 11%. Conclusion: Interventions focusing on postoperative pancreatic fistula and postpancreatectomy hemorrhage may have the greatest impact on in-hospital mortality and organ failure. To prevent prolonged hospital stay, initiatives should in addition focus on delayed gastric emptying.

Is primary total pancreatectomy in patients with high-risk pancreatic remnant justified and preferable to pancreaticoduodenectomy? —a matched-pairs analysis of 200 patients

“…Despite major developments in surgical technique and perioperative management, rates of POPF and PPH remain a constant and unsolved problem after PD and represent the most relevant triggers of mortality (1)(2)(3)(4)(5). After its introduction in 1942 by Rockey, TP was advocated by some pioneers of pancreatic surgery as prophylaxis of POPF and its associated morbidity and mortality, but abandoned later due to the lack of oncologic benefit and the detrimental effects of apancreatic state (7-10).…”

“…Reconstruction after pancreaticoduodenectomy (PD) in the presence of soft pancreatic remnant and small-sized pancreatic duct is a challenge even to the experienced pancreatic surgeon. These features are recognized as major risk factors for postoperative pancreatic fistula (POPF), which itself remains the most relevant source of morbidity after PD (1,2). Rates of clinically relevant POPF are well above 20% at high-volume centers, reaching even 40% in the subgroup of patients with high-risk pancreatic remnant (3)(4)(5).…”

“…Rates of clinically relevant POPF are well above 20% at high-volume centers, reaching even 40% in the subgroup of patients with high-risk pancreatic remnant (3)(4)(5). POPF has the potential to cause life-threatening secondary complications such as postpancreatectomy hemorrhage (PPH), intraabdominal abscess, and sepsis, leading to increased costs, prolonged hospital stay as well as to delayed chemotherapy in oncologic patients (2,6).…”

Pancreatic Fistula after D1+/D2 Radical Gastrectomy according to the Updated International Study Group of Pancreatic Surgery Criteria: Risk Factors and Clinical Consequences. Experience of Surgeons with High Caseloads in a Single Surgical Center in Eastern Europe

“…In this study, POPF occurrence was associated with statistically significant increased rates of postoperative bleeding requiring re-laparotomy (P=0.029), anastomotic leak (P=0.002), 90-day mortality (P=0.036) and prolonged hospital stay (P<0.001). It is widely accepted that a POPF can lead to other serious complications such as bleeding, intra-abdominal sepsis, and anastomotic leak, which are all associated with prolonged hospital stays [ 16 17 49 64 ] and increased mortality rates [ 66 67 ]. Enzymatic, local septic vascular, or visceral erosions in the setting of POPF formation might explain the increased rates of late hemorrhage and anastomotic leak.…”

Hospital costs of delayed gastric emptying following pancreatoduodenectomy and the financial headroom for novel prophylactic treatment strategies

“…[7][8][9][10] A recent nationwide study demonstrated that when the focus is to reduce length of stay, DGE should be prioritized as this complication may hamper clinical improvement for several weeks. 11 In addition to the economic impact, DGE also has a considerable clinical impact. Patients with DGE are unable to tolerate solid food and experience vomiting and/or gastric distension requiring prolonged nasogastric drainage, nasoenteral tube feeding or even parenteral feeding.…”