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

Disclosures

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

In This Article

Methods

Patient Population

The 2013 to 2017 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Participant Use Files (PUFs) and the 2014 to 2017 Pancreatectomy Targeted PUFs were queried to identify patients undergoing elective PD and DP. In 2014, 106 participating institutions from North America participated in procedure-targeted pancreatectomy data collection. Over the course of the study period, the number of institutions increased to include 142 centers by 2017. Of the contributing centers in 2017, 130 were from the United States, 8 were Canadian, and 4 were from other outside of North America including Australia, Lebanon, and Singapore. We estimate that the 6918 cases included in the 2017 dataset represent 60% to 70% of North American pancreatectomies.

Patients 18 years of age or older who underwent PD were identified using primary Current Procedural Terminology (CPT) codes 48150, 48152, 48153, and 48154, and those who underwent DP were identified using primary CPT codes 48140 and 48146. Patients with a nonelective or emergent operation were excluded, as were those who underwent concurrent colectomy (CPTs 44140–44160 and 44204–44212) or major hepatectomy (CPTs 47122, 47125, and 47130). Lastly, for patients with concurrent PD and DP, CPTs were excluded as designations may have occurred due to coding errors. Due to the de-identified nature of patient data included in the PUFs, this study was designated exempt from review by the Institutional Review Board at the University of Pittsburgh Medical Center.

Variables and Definitions

Multiple patient, process, procedure, and 30-day postoperative outcome variables were captured and analyzed over time. Preoperative patient conditions included pancreatic cancer, neoadjuvant therapy, and biliary stent placement. Perioperative variables included operative approach (ie, open or minimally invasive), vascular resection, pylorus perseveration, pancreaticojejunal duct-to-mucosal anastomosis, pancreaticojejunal invagination, pancreaticogastrostomy, operative time, and transfusions. Process variables included drain placement, whether drain amylase was recorded on postoperative day (POD) 1, whether drains were removed by POD 3, and whether drains were removed by POD 3 given that POD 1 drain amylase was <5000 IU/L.

Examined postoperative outcomes included surgical site infection (SSI), including superficial, deep, and organ space, wound dehiscence, pneumonia, unplanned intubation, ventilator dependence >48 hours, venous thromboembolism (VTE), progressive renal insufficiency or acute renal failure, urinary tract infection, stroke or cerebrovascular accident, cardiac arrest, myocardial infarction, sepsis or septic shock, postoperative pancreatic fistula (POPF), clinically relevant postoperative pancreatic fistula (CR-POPF), delayed gastric emptying, percutaneous drainage, unplanned reoperation, prolonged postoperative length of stay (LOS), discharge not to home, unplanned readmission, and mortality.[13] The definition of POPF used in this study was based on that of the International Study Group for Pancreatic Surgery (ISGPS) and included biochemical leaks (BLs).[14] POPF was defined as persistent drain output of amylase-rich fluid [amylase >300 U/L on POD 3 or later (ISGPS BL)] in combination with either a drain remaining in place for longer than 7 days, need for percutaneous drain placement, or reoperation; or as determined by the attending surgeon in the presence of either a drain in placed longer than 7 days, spontaneous wound drainage, percutaneous drainage, or reoperation. The definition of CR-POPF was also based on that of the ISGPS and has been described previously.[15] CR-POPF included the presence of fistula in addition to a hospital LOS of ≥14 days (not included in ISGPS definition), a drain in place for longer than 21 days, organ space SSI, sepsis, postoperative drain placement (ISGPS grade B) or shock, organ failure, need for reoperation or death (ISGPF grade C).[14,15] Unlike the ISGPS definition, postpancreatectomy hemorrhage was not included as angiographic interventions were not variables recorded as part of ACS-NSQIP during the study period. Patients were considered to have an "acceptable" postoperative LOS if they remained in the hospital for equal to or less than the 75th percentile for PD (12 days) or DP (7 days).

Three postoperative composite outcomes were examined. Two of these outcomes, overall and serious morbidity, are defined in eTable 1 (http://links.lww.com/SLA/B796).[16] The third and primary endpoint for this study was "optimal pancreatic surgery," which was defined as the absence of postoperative mortality, serious morbidity, percutaneous drainage, and reoperations while maintaining an acceptable postoperative LOS (<75th percentile) with no readmission.

Statistical Analysis

Pancreatoduodenectomy and DP patients were considered separately for all analyses. Unadjusted time-trend analyses were performed: the time periods examined were 2013 to 2017 for nonpancreatectomy-specific factors, and 2014 to 2017 for pancreatectomy-specific factors, because these were not available in 2013. Additionally, risk-adjusted time-trend analyses were performed for postoperative outcomes: the time period examined was 2014 to 2017.

Logistic regression was used to analyze all outcomes except for operative time and postoperative LOS, which were analyzed using gamma regression. The primary predictor of interest was the year of operation as indicated by PUF year. Threshold for statistical significance was set at a P value ≤0.05. For risk-adjusted analyses of postoperative outcomes, a backwards selection procedure was utilized to choose among the following predictors: age, sex, body mass index (BMI), various comorbidities [diabetes, current smoker, dyspnea, history of chronic obstructive pulmonary disease (COPD), and hypertension], disseminated cancer, weight loss, American Society of Anesthesiologists (ASA) classification, preoperative jaundice, biliary stent, neoadjuvant chemotherapy/radiotherapy, minimally invasive operative approach, pylorus-preservation, and pancreatic cancer.

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