Outcome of Pancreaticoduodenectomy at Low-Volume Centre in Tier-II City of India

Abstract

Currently, pancreaticoduodenectomy (PD) is considered a common and feasibly performed surgery for periampullary tumours, but it is still a high-risk surgical procedure with potential morbidity and mortality rates. Previously, it was emphasised for the need of high-volume centres to perform specialised surgery such as PD. The authors have made an attempt to know the relation between low-volume centre and outcomes of PD. The study was conducted in a Tier-II city referral hospital located in Karnataka, India. A total of 37 patients with suspected periampullary neoplasms underwent surgical exploration with curative intent over a period of 4 years, i.e. from May 2012 to May 2016. Out of 37 patients, 26 underwent PD, either classic Whipple resection ( = 01) or pylorus-preserving modification ( = 25). In 11 patients, resection was not possible, where biliary and gastric drainage procedures were done. All patients were treated by standardised post-operative care protocols for pancreatic resection used at our centre. We recorded the perioperative outcome along with demographics, indications for surgery, and pre- and intra-operative factors of PD. Post-operative pancreatic fistulae were evident in 4 patients. Two patients had hepaticojejunostomy leak. One patient had chyle leak. Three patients had infection at the surgical site. One patient had post-operative pneumonia leading to mortality. None of the patients had post-op haemorrhage. The surgeon volume and surgeon experience may have minimal contributing factor in post-operative morbidity, especially if there is availability of well-equipped ICU and imaging facilities, along with well-experienced personnel like oncosurgeon, anaesthesiologist, intensivist, radiologist, and nursing staff. There is a need of a multicentre study from Tier-II city hospitals/low-volume centres and high-volume centres to come with perioperative surgical outcomes following PD.

Postoperative pancreatic fistulas after pancreaticoduodenectomy for malignancy: A Northeast Indian tertiary cancer center study

“…The reported postoperative fistula rates at three other centers from India were 15%, 15.39%, and 12% respectively, 24–26 and the fistula rate at our center was 17.0%. Studies have shown that high volume centers and high volume surgeons provide best outcomes after pancreaticoduodenectomy 25,27,28 . Pancreaticoduodenectomy is associated with major postoperative complications.…”

“…At high volume centers, apart from availability of enough resources, they are usually equipped with experienced team (critical care team, intervention radiologists, experienced surgeons, and nursing staff), which can improve postoperative outcomes of patients by timely identification and intervention for management of these complications 29 . A study from India has shown that even at low volume centers, outcomes of patients after pancreatic surgery are minimally affected if hospital is equipped with better infrastructure and experienced team who can manage postoperative complications 25 . We consider our institute in a transition phase from low volume to high volume center.…”

“…Studies have shown that high volume centers and high volume surgeons provide best outcomes after pancreaticoduodenectomy. 25 , 27 , 28 Pancreaticoduodenectomy is associated with major postoperative complications. At high volume centers, apart from availability of enough resources, they are usually equipped with experienced team (critical care team, intervention radiologists, experienced surgeons, and nursing staff), which can improve postoperative outcomes of patients by timely identification and intervention for management of these complications.…”

Nursing interventions to reduce surgical site infection in potentially contaminated surgeries: an integrative review

“…The articles found in this research 11,13,15,18 highlighted the importance of chlorhexidine bath in patients with potentially contaminated surgeries for the prevention of SSI. It is recommended that the bath should be performed with soap and water, the night before or the morning of surgery 3,28 ; there is no consensus on the indication of the use of antiseptic for all surgeries, however, its use is indicated in large surgeries, with implants or in cases of outbreaks of infection in surgeries. Trichotomy should be performed only when necessary, immediately before the surgical procedure, without the use of blades, prioritizing the use of electric tricotomizers, trimmers or scissors 11,19 , being in accordance with the Healthcare related infection prevention measures established by the Brazilian Ministry of Health 24 .…”

“…Intraoperative nursing interventions are associated with surgical environment 15,18,19 , surgical antisepsis of the hands with degermating antiseptic or alcohol-based product 15,19, potential for contamination of operative wound 18,19 , surgical duration 19 and sterile glove replacement 15 . These interventions were also recommended in national 1,8 and international original articles 28 , national 29 and international systematic reviews 30 , and in the recommendations established by the Centers for Disease Control and Prevention (CDC) 31 .…”