International validation and update of the Amsterdam model for prediction of survival after pancreatoduodenectomy for pancreatic cancer

Abstract

Background: Chronic pancreatitis is a complex disease associated with recurrent hospitalizations and interventions. A lack of standardized management algorithms and lack of access to the necessary highly specialized physicians has led to highly variable care for these patients. The purpose of this study was to evaluate the trends in management of patients with chronic pancreatitis in the United States. Methods: A retrospective analysis of the Nationwide Inpatient Sample (HCUP-NIS) from 2007 to 2016 was performed. Patients 18 years of age and older who were admitted under primary diagnosis of chronic pancreatitis were included for analysis. Patient demographic factors, interventions (surgical, endoscopic, percutaneous), length of stay, discharge disposition, and mortality over the study period were evaluated. Statistical analyses to evaluate significant trends in care were performed. Results: 32,563 patients (age 48.87AE13.9 years, 49.1% female) were analyzed. Alcoholic chronic pancreatitis was identified in 8793 patients (27%). Average overall length of stay was 5AE5.7 days. The majority of the patients were discharged home to self-care (72.0%), 1.6% were discharged to an inpatient rehab, 6.7% with home health care, and 3.2% were sent to skilled nursing facility. 114 (0.4%) of patients died during their hospitalization. 4904 patients (15.1%) underwent interventions, which increased during the study period from 13.3% in 2007 to 15.8% in 2016 (P < 0.001). Endoscopic interventions were performed in 2462 (7.6%) and percutaneous procedures in 440 (1.4%) patients, which were both stable during the study period. Surgery was performed on 2235 (6.9%) patients, which increased from 4.8% in 2007 to 8.2% in 2016 (P < 0.001). Pancreatic surgical procedures were the most common (2187 of 2235; 97.9%), of which resective procedures were most commonly performed (1589/2187; 72.7%). Pancreatic surgical procedures increased in frequency over the study period from 4.7% in 2007 to 7.6% in 2016 (P < 0.001), with resective procedures increasing from 3.3% to 6.1% (P < 0.001). Overall mortality was 0.9% in surgical group (P < 0.001), but 0.4% in patients with endoscopic interventions (P=0.893). Conclusion:There is an increasing rate of interventions being performed on chronic pancreatitis patients in the United States. Surgical procedures are becoming more frequently performed on chronic pancreatitis patients, with an increased frequency and predominance of resective procedures. These results suggest a surprisingly long length of stay and low rate of endoscopic interventions compared to surgical interventions. There is therefore a need for evidence-based consensus guidelines for the management of chronic pancreatitis, including centralization of care to centers with advanced endoscopic and surgical specialists.