Variation in hospital mortality after pancreatoduodenectomy is related to failure to rescue rather than major complications: a nationwide audit

Rijssen, L.B. van; Zwart, M.; Dieren, Susan van; Rooij, Thijs de; Bonsing, Bert A.; Bosscha, K.; Dam, Ronald M. van; Eijck, Casper H. van; Gerhards, Michael F.; Gerritsen, Josephus J.; Harst, Erwin van der; Hingh, Ignace H. J. T. de; Jong, Koert P. de; Kazemier, Geert; Klaase, Joost M.; Kolk, B.M. van der; Laarhoven, Cornelis J. van; Luyer, Misha; Molenaar, I. Quintus; Patijn, Gijs A.; Rupert, C.; Scheepers, Joris J.; Schelling, George P. van der; Vahrmeijer, Alexander L.; Busch, Olivier R.; Santvoort, Hjalmar C. van; Koerkamp, Bas Groot; Besselink, Marc G.; Gulik, Thomas M. van; Festen, Sebastiaan; Karsten, Tom; Coene, P. P. L. O.

doi:10.1016/j.hpb.2018.02.640

Cited by 93 publications

(87 citation statements)

References 45 publications

(70 reference statements)

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“…Centres were grouped into four categories based on their mean annual PD volume using previously established volume cut-off values 6,17 : very low (fewer than 10 PDs per year), low (10)(11)(12)(13)(14)(15)(16)(17)(18)(19) PDs per year), medium (20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39) PDs per year) and high (at least 40 PDs per year).…”

Section: Volume Definitionsmentioning

confidence: 99%

Variation in pancreatoduodenectomy as delivered in two national audits

Mackay

Wellner

Rijssen

et al. 2019

British Journal of Surgery

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Background: Nationwide audits facilitate quality and outcome assessment of pancreatoduodenectomy. Differences may exist between countries but studies comparing nationwide outcomes of pancreatoduodenectomy based on audits are lacking. This study aimed to compare the German and Dutch audits for external data validation.Methods: Anonymized data from patients undergoing pancreatoduodenectomy between 2014 and 2016 were extracted from the German Society for General and Visceral Surgery StuDoQ|Pancreas and Dutch Pancreatic Cancer Audit, and compared using descriptive statistics. Univariable and multivariable risk analyses were undertaken.Results: Overall, 4495 patients were included, 2489 in Germany and 2006 in the Netherlands. Adenocarcinoma was a more frequent indication for pancreatoduodenectomy in the Netherlands. German patients had worse ASA fitness grades, but Dutch patients had more pulmonary co-morbidity. Dutch patients underwent more minimally invasive surgery and venous resections, but fewer multivisceral resections. No difference was found in rates of grade B/C postoperative pancreatic fistula, grade C postpancreatectomy haemorrhage and in-hospital mortality. There was more centralization in the Netherlands (1⋅3 versus 13⋅3 per cent of pancreatoduodenectomies in very low-volume centres; P < 0⋅001). In multivariable analysis, both hospital stay (difference 2⋅49 (95 per cent c.i. 1⋅18 to 3⋅80) days) and risk of reoperation (odds ratio (OR) 1⋅55, 95 per cent c.i. 1⋅22 to 1⋅97) were higher in the German audit, whereas risk of postoperative pneumonia (OR 0⋅57, 0⋅37 to 0⋅88) and readmission (OR 0⋅38, 0⋅30 to 0⋅49) were lower. Several baseline and surgical characteristics, including hospital volume, but not country, predicted mortality.Conclusion: This comparison of the German and Dutch audits showed variation in case mix, surgical technique and centralization for pancreatoduodenectomy, but no difference in mortality and pancreasspecific complications.

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Section: Volume Definitionsmentioning

confidence: 99%

Variation in pancreatoduodenectomy as delivered in two national audits

Mackay

Wellner

Rijssen

et al. 2019

British Journal of Surgery

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“…Centralisation and increasing hospital volumes have been shown to improve post‐operative and long‐term survival for PD . However, a suggested explanation is that improvement in mortality could be related to an increased ability to rescue from death after major complications . The data presented here show a Victorian median public hospital volume of eight PD per year with the highest volume hospital performing 20 PD per year.…”

Section: Discussionmentioning

confidence: 71%

“…5,18 However, a suggested explanation is that improvement in mortality could be related to an increased ability to rescue from death after major complications. 6,19,20 The data presented here show a Victorian median public hospital volume of eight PD per year with the highest volume hospital performing 20 PD per year. By most definitions, these are not high volume centres and yet the mortality results are comparable to internationally reported values.…”

Section: Discussionmentioning

confidence: 75%

Short‐term outcomes of pancreaticoduodenectomy in the state of Victoria: hospital resources are more important than volume

Stevens

Watters

2019

ANZ Journal of Surgery

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Background Pancreaticoduodenectomy (PD) is a high‐risk procedure. Australian hospitals perform a relatively low volume of PD. This study sought to gain an understanding of hospital volume and short‐term outcomes of the procedure in the Australian state of Victoria. Methods The Dr Foster Quality Investigator tool was used to interrogate the Victorian Admitted Episodes Database for the Australian Classification of Health Intervention code for PD (30584) from July 2010 to June 2016. The data set included patients from a peer group of 14 hospitals that included all the public hospitals performing PD during this period. Patient characteristics, inpatient mortality, 30‐day readmission rates and median length of stay were reported for each de‐identified hospital. Results There were 547 PD conducted over 6 years in 10 public hospitals. The median patient age was 65 years. Inpatient mortality was 2.7%. There was a significant risk adjusted difference in mortality between principal referral and other public hospitals. Annual hospital volume ranged from 3 to 20 PD, and there was no significant relationship between mortality, readmission rates or length of stay and hospital volume. Conclusion The inpatient mortality associated with PD in Victorian public hospitals is comparable to that seen in overseas studies. While hospital volume is relatively low, there does not seem to be a relationship between volume and short‐term outcomes. Variability between hospital peer groups suggests that resource availability is more important than volume. The development of a procedure specific registry would be useful to test the outcomes of this study and determine long‐term PD outcomes.

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“…When not recognized early, pancreatic fistula may have major impact on the clinical course and is associated with an increased risk of in-hospital death, prolonged hospital stay, lower chance of receiving adjuvant chemotherapy and impaired long-term survival [3,5,42]. A recent study showed that the difference in clinical outcome in Dutch centers can be explained in difference in failure to rescue rate rather than incidence of major complications [11]. In the Netherlands, pancreatic surgery is centralized in high volume centers (i.e.…”

Section: Discussionmentioning

confidence: 99%

“…This variability appears to be explained by differences in failure to rescue rates between centers (i.e. mortality in patients with major postoperative complications) [11].…”

Section: Introductionmentioning

confidence: 99%

Care after pancreatic resection according to an algorithm for early detection and minimally invasive management of pancreatic fistula versus current practice (PORSCH-trial): design and rationale of a nationwide stepped-wedge cluster randomized trial

Smits

Henry

Eijck

et al. 2020

Preprint

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Background Pancreatic resection is a major abdominal operation with 50% risk of postoperative complications. A common complication is pancreatic fistula, which may have severe clinical consequences such as postoperative bleeding, organ-failure and death. The objective of this study is to investigate whether implementation of an algorithm for early detection and minimally invasive management of pancreatic fistula may improve outcomes after pancreatic resection. Methods This is a nationwide stepped-wedge, cluster randomized, superiority trial, designed in adherence to the CONSORT guidelines. During a period of 22 months, all Dutch centers performing pancreatic surgery will cross over in a randomized order from current practice to best practice according to the algorithm. This evidence- and consensus based algorithm will provide daily multilevel advice on the management of patients after pancreatic resection (i.e. indication for abdominal imaging, antibiotic treatment, percutaneous drainage and removal of abdominal drains). The algorithm is designed to aid early detection and minimally invasive step-up management of postoperative pancreatic fistula. Outcomes of current practice will be compared with outcomes after implementation of the algorithm. The primary outcome is a composite of major complications (i.e. postpancreatectomy bleeding, new-onset organ failure and death) and will be measured in a sample size of at least 1600 patients undergoing pancreatic resection. Secondary endpoints include the individual components of the primary endpoint and other clinical outcomes, healthcare resource utilization and costs analysis. Follow-up will be up to 90 days after pancreatic resection. Discussion It is hypothesized that a structured nationwide implementation of a dedicated algorithm for early detection and minimally invasive step-up management of postoperative pancreatic fistula will reduce the risk of major complications and death after pancreatic resection, as compared to current practice.

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Variation in hospital mortality after pancreatoduodenectomy is related to failure to rescue rather than major complications: a nationwide audit

Abstract: Variations in mortality between hospitals after pancreatoduodenectomy were explained mainly by differences in FTR, rather than the incidence of major complications.

Cited by 93 publications

References 45 publications

Variation in pancreatoduodenectomy as delivered in two national audits

Variation in pancreatoduodenectomy as delivered in two national audits

Short‐term outcomes of pancreaticoduodenectomy in the state of Victoria: hospital resources are more important than volume

Care after pancreatic resection according to an algorithm for early detection and minimally invasive management of pancreatic fistula versus current practice (PORSCH-trial): design and rationale of a nationwide stepped-wedge cluster randomized trial

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