Whipple-specific complications result in prolonged length of stay not accounted for in ACS-NSQIP Surgical Risk Calculator

Cusworth, Brian; Krasnick, Bradley A.; Nywening, Timothy M.; Woolsey, Cheryl A.; Fields, Ryan C.; Doyle, M.; Liu, Jingxia; Hawkins, William G.

doi:10.1016/j.hpb.2016.10.015

Cited by 41 publications

(28 citation statements)

References 36 publications

(35 reference statements)

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“…This also helps explain the fact that while more of our trauma patients survived, we did find that TP patients had a higher risk of major complications compared to similar patients undergoing laparotomy. This continued high rate/risk of complications is mirrored in the elective pancreaticoduodenectomy literature with complication rates as high as 45% [20,32]. Additionally, the low rate of unplanned returns to the operating room found in this study support the fact that complications can often be dealt with in a more minimally invasive manner thus improving mortality outcomes.…”

Section: Discussionsupporting

confidence: 64%

“…However, TP has failed to gain wide popularity among trauma surgeons likely due to reports of morbidity and mortality rates up to 80% and 50%, respectively [ 16 – 19 ]. However, the national trend for mortality after elective pancreaticoduodenectomy has improved from 25 to below 4%; a trend partly attributed to the advent of minimally invasive salvage techniques such as interventional radiology, endoscopic retrograde cholangiopancreatography, and improved critical care [ 20 – 22 ]. Therefore, we hypothesized no difference in risk of mortality between contemporary penetrating trauma patients with severe pancreatic or duodenal injury undergoing a TP to propensity-matched controls undergoing laparotomy without TP.…”

Section: Introductionmentioning

confidence: 99%

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The modern trauma pancreaticoduodenectomy for penetrating trauma: a propensity-matched analysis

et al. 2020

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Trauma pancreaticoduodenectomy (TP) remains a challenging operation with morbidity and mortality rates as high as 80% and 50%. Many trauma surgeons consider it surgical dogma to avoid performing a TP during the index operation for patients with severe pancreatic or duodenal injuries. However, there is no modern analysis evaluating this belief. Therefore, we hypothesized no difference in risk of mortality between patients with severe pancreatic or duodenal injury undergoing a TP for penetrating trauma to propensity-matched controls undergoing laparotomy without TP. The Trauma Quality Improvement Program (2010-2016) was queried for adults with severe penetrating pancreatic or duodenal injuries undergoing laparotomy. A 1:2 propensity-matching including demographics/comorbidities, injury severity score, vitals on admission, Glasgow Coma Scale and concomitant injuries for laparotomy with or without TP was performed. Risk of mortality was reported using a univariable logistic regression model. Of 2182 patients with severe pancreatic or duodenal injuries undergoing laparotomy, 54 (2.5%) underwent TP and 2128 (97.5%) underwent laparotomy without TP. There were no differences in propensitymatching characteristics. Patients undergoing TP had a similar mortality rate (20.0% vs. 28.7%, p = 0.302) but a longer length of stay (LOS) (27.5 vs. 16.5 days, p = 0.017). The TP group had a similar associated risk of mortality (OR = 0.62, p = 0.302) but higher risk of major complications (OR 3.44, CI 1.35-17.47, p = 0.015). In appropriately selected penetrating trauma patients with severe pancreatic/duodenal injuries, TP is associated with a similar risk of mortality compared to laparotomy without TP. However, TP patients did have an increased associated risk of major complications and longer LOS.

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Section: Discussionsupporting

confidence: 64%

Section: Introductionmentioning

confidence: 99%

The modern trauma pancreaticoduodenectomy for penetrating trauma: a propensity-matched analysis

et al. 2020

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“…Pancreaticoduodenectomy (PD) is the most effective treatment for an ampullary tumor, which is associated with high morbidity and mortality rates, even if the complex procedure is performed in tertiary centers. [ 1 , 2 ] Anatomical variations of the hepatic artery and celiac trunk put an individual at a high risk of injury to the arterial supply and, subsequently, to severe hepatic ischemia, liver abscesses, biliary fistula, or hemorrhage. [ 1 ] Therefore, the accurate identification of these arterial variations would enhance the probability of successful surgery and decrease the rate of complications after the complex PD procedure.…”

Section: Introductionmentioning

confidence: 99%

A rare variation of celiac trunk and hepatic artery complicating pancreaticoduodenectomy

Zhou

Ye²,

Zhou³

et al. 2017

Medicine

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Rationale:Anatomical variations of the celiac trunk and the hepatic artery are of considerable importance in hepatopancreatobiliary surgery, liver transplants, and radiological abdominal interventions.Patient concerns:Here, we report a 57-year-old man with 2 weeks of painless progressive jaundice. Preoperative imaging and cytology brush results suggested an ampullary tumor and common hepatic artery anomaly (CTA) was reported. The patient underwent pancreaticoduodenectomy (PD). Intraoperatively, the CHA and gastroduodenal artery (GDA) were abnormal. The CHA emerged from the superior mesenteric artery (SMA). Computer tomography angiography (CTA) was performed postoperatively; surprisingly, the left gastric artery (LGA) and splenic artery (SA) arising from the anterior wall of the abdominal aorta replaced the normal structure of the celiac trunk, and an accessory left hepatic artery (LHA) emerged from the LGA.Diagnoses:The patient was diagnosed with cholangiocarcinoma and accompanying extremely rare variation of celiac trunk and hepatic artery.Interventions and outcomes:The patient underwent PD and had an uneventful postoperative evolution. There was no recurrence of the tumor and with normal liver function during the 10-month follow-up.Interventions:The patient underwent PD and had an uneventful postoperative evolution.Outcomes:There was no recurrence of the tumor and with normal liver function during the 10-month follow-up.Lessons:Surgeons must keep in mind that arterial variation may be present in the vascular structures intraoperatively, even if it was not revealed in preoperative imaging. The preoperative identification of arterial variation and its relationship with the tumor is necessary to avoid intraoperative vascular injury and complications after surgery.

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“…5 Such a prolonged hospitalization subjects patients to significant risk for debility and iatrogenic complications, ranging from hospital-acquired infections to medical error. 6,7 Enhanced recovery after surgery (ERAS) pathways emphasizing multidisciplinary, modern perioperative care can decrease complications, hasten recovery, shorten hospital LOS, and control costs. 8 Pancreaticoduodenectomyspecific ERAS pathways incorporating evidence-based dietary protocols, rehabilitation, and the standardization of level of care have proved effective in preventing medical error, coordinating care, and reducing median LOS to as low as 7 to 8 days at some of the highest-volume centers.…”

mentioning

confidence: 99%

Enhancing Patient Outcomes while Containing Costs after Complex Abdominal Operation: A Randomized Controlled Trial of the Whipple Accelerated Recovery Pathway

Lavu

McCall

Winter

et al. 2019

Journal of the American College of Surgeons

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BACKGROUND: This study was designed to determine whether a standardized recovery pathway could reduce post-pancreaticoduodenectomy hospital length of stay to 5 days without increasing complication or readmission rates. STUDY DESIGN: Pancreaticoduodenectomy patients (high-risk patients excluded) were enrolled in an IRBapproved, prospective, randomized controlled trial (NCT02517268) comparing a 5-day Whipple accelerated recovery pathway (WARP) with our traditional 7-day pathway (control). Whipple accelerated recovery pathway interventions included early discharge planning, shortened ICU stay, modified postoperative dietary and drain management algorithm, rigorous physical therapy with in-hospital gym visit, standardized rectal suppository administration, and close telehealth follow-up post discharge. The trial was powered to detect an increase in postoperative day 5 discharge from 10% to 30% (80% power, a ¼ 0.05, 2sided Fisher's exact test, target accrual: 142 patients). RESULTS: Seventy-six patients (37 WARP, 39 control) were randomized from June 2015 to September 2017. A planned interim analysis was conducted at 50% trial accrual resulting in mandatory early stoppage, as the predefined efficacy end point was met. Demographic variables between groups were similar. The WARP significantly increased the number of patients discharged to home by postoperative day 5 compared with controls (75.7% vs 12.8%; p < 0.001) without increasing readmission rates (8.1% vs 10.3%; p ¼ 1.0). Overall complication rates did not differ between groups (29.7% vs 43.6%; p ¼ 0.24), but the WARP significantly reduced the time from operation to adjuvant therapy initiation (51 days vs 66 days; p ¼ 0.005) and hospital cost ($26,563 vs $31,845; p ¼ 0.011). CONCLUSIONS: The WARP can safely reduce hospital length of stay, time to adjuvant therapy, and cost in selected pancreaticoduodenectomy patients without increasing readmission risk.

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Whipple-specific complications result in prolonged length of stay not accounted for in ACS-NSQIP Surgical Risk Calculator

Cited by 41 publications

References 36 publications

The modern trauma pancreaticoduodenectomy for penetrating trauma: a propensity-matched analysis

The modern trauma pancreaticoduodenectomy for penetrating trauma: a propensity-matched analysis

A rare variation of celiac trunk and hepatic artery complicating pancreaticoduodenectomy

Enhancing Patient Outcomes while Containing Costs after Complex Abdominal Operation: A Randomized Controlled Trial of the Whipple Accelerated Recovery Pathway

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