Optimal Pancreatic Surgery: Are We Making Progress in North America?

Joal D. Beane, MD; Jeffrey D. Borrebach, MS; Amer H. Zureikat, MD; E. Molly Kilbane, RN; Vanessa M. Thompson, PhD; Henry A. Pitt, MD


Annals of Surgery. 2021;274(4):e355-e363. 

In This Article

Abstract and Introduction


Objective: Our aims were to assess North American trends in the management of patients undergoing pancreatoduodenectomy (PD) and distal pancreatectomy (DP), and to quantify the delivery of optimal pancreatic surgery.

Background: Morbidity after pancreatectomy remains unacceptably high. Recent literature suggests that composite measures may more accurately define surgical quality.

Methods: The 2013 to 2017 American College of Surgeons National Surgical Quality Improvement Program Participant Use Files were queried to identify patients undergoing PD (N = 16,222) and DP (N = 7946). Patient, process, procedure, and 30-day postoperative outcome variables were analyzed over time. Optimal pancreatic surgery was defined as the absence of postoperative mortality, serious morbidity, percutaneous drainage, and reoperation while achieving a length of stay equal to or less than the 75th percentile (12 days for PD and 7 days for DP) with no readmissions. Risk-adjusted time-trend analyses were performed using logistic regression, and the threshold for statistical significance was P ≤ 0.05.

Results: The use of minimally invasive PD did not change over time, but robotic PD increased (2.5 to 4.2%; P < 0.001) and laparoscopic PD decreased (5.8% to 4.3%; P < 0.02). Operative times decreased (P < 0.05) and fewer transfusions were administered (P < 0.001). The percentage of patients with a drain fluid amylase checked on postoperative day 1 increased (P < 0.001), and a greater percentage of surgical drains were removed by postoperative day 3 (P < 0.001). Overall morbidity (P < 0.02), mortality (P < 0.05), and postoperative length of stay (P = 0.002) decreased. Finally, the rate of optimal pancreatic surgery increased for PD (53.7% to 56.9%; P < 0.01) and DP (53.3% to 58.5%; P < 0.001), and alspo for patients with pancreatic cancer (P < 0.01).

Conclusions: From 2013 to 2017, pre, intra, and perioperative pancreatectomy processes have evolved, and multiple postoperative outcomes have improved. Thus, in 4 years, optimal pancreatic surgery in North America has increased by 3% to 5%.


The reporting and analysis of postoperative outcomes and the conduction of innovative clinical trials have resulted in a growing body of evidence aimed to improve the delivery of care for patients undergoing pancreatoduodenectomy (PD) and distal pancreatectomy (DP). Significant strides have been achieved over the past 3 decades in reducing mortality of pancreatectomy to under 2%;[1–3] however, morbidity remains unacceptably high.[4,5] Despite exhaustive efforts by surgeons and researchers to develop and test strategies aimed at reducing morbidity, limited evidence demonstrates how practice patterns or processes of care have changed over time. In addition, whether changes in practice have translated into the delivery of improved postoperative outcomes is unknown.

Recent reports suggest that composite measures of patient outcomes, already used by payers and large healthcare purchasers to guide referrals and value-based purchasing programs, may be more representative descriptors of quality compared with the reporting of individual outcomes.[6–8] While composite measures provide a less granular assessment and have known limitations, they are more accurate in providing a global picture of quality and may be better suited to predict future performance.[8,9] The reporting of "textbook outcomes" and the establishment of "benchmarks" to define quality are attractive approaches to measure progress in the delivery of care for patients undergoing pancreatectomy.[4,10–12] These composite measures also allow the detection of variation among surgeons, hospitals, and healthcare systems. To better assess trends over time in the quality of care for patients undergoing PD and DP, the composite outcome of "optimal pancreatic surgery" was developed. The aims of this study were to analyze whether changes in practice patterns and processes of care have influenced the outcomes of North American patients undergoing PD and DP. The percentage of patients receiving optimal pancreatic surgery over time was the primary outcome.