Benchmarks in Pancreatic Surgery

Abstract

OBJECTIVE To use the concept of benchmarking to establish robust and standardized outcome references after pancreatico-duodenectomy (PD). BACKGROUND Best achievable results after PD are unknown. Consequently, outcome comparisons among different cohorts, centers or with novel surgical techniques remain speculative. METHODS This multicenter study analyzes consecutive patients (2012-2015) undergoing PD in 23 international expert centers in pancreas surgery. Outcomes in patients without significant comorbidities and major vascular resection (benchmark cases) were analyzed to establish 20 outcome benchmarks for PD. These benchmarks were tested in a cohort with a poorer preoperative physical status (ASA class 3) and a cohort treated by minimally invasive approaches. RESULTS Two thousand three hundred seventy-five (38%) low-risk cases out of a total of 6186 PDs were analyzed, disclosing low in-hospital mortality (1.6%) but high morbidity, with a 73% benchmark morbidity rate cumulated within 6 months following surgery. Benchmark cutoffs for pancreatic fistulas (B-C), severe complications (grade 3), and failure-to-rescue rate were 19%, 30%, and 9%, respectively. The ASA 3 cohort showed comparable morbidity but a higher in hospital-mortality (3% vs 1.6%) and failure-to-rescue rate (16% vs 9%) than the benchmarks. The proportion of benchmark cases performed varied greatly across centers and continents for both open (9%-93%) and minimally invasive (11%-62%) PD. Centers operating mostly on complex PD cases disclosed better results than those with a majority of low-risk cases. CONCLUSION The proposed outcome benchmarks for PD, established in a large-scale international patient cohort and tested in 2 different cohorts, may allow for meaningful comparisons between different patient cohorts, centers, countries, and surgical techniques.

Evidence map of pancreatic surgery: protocol for a living systematic review and meta-analysis

“…For both entities, surgery remains the only chance of cure or long-term increase of quality of life, respectively 2 3. Therefore, all patients bear the burden of a severe disease in need of major surgery, and must carry the risk of postoperative morbidity which is as high as 73% 4. Therefore, one of the major research interests is to find the most effective and safe way to operate patients.…”

Systematic review and meta-analysis of surgical drain management after the diagnosis of postoperative pancreatic fistula after pancreaticoduodenectomy: draining-tract-targeted works better than standard management

“…We believe that POPF-related mortality rate is a very important objective parameter to be evaluated, at least as important as complication rate and hospital stay. Unfortunately, neither the International Study Group on Pancreatic Surgery (ISGPS) [33] nor 23 International Expert Centers in pancreas surgery [3] included an accurate definition of POPF-related mortality rate among the outcome parameters of pancreatic surgery.…”

“…(2) clearly defined pathology procedures (for benign or malignant pancreatic lesions), and surgical procedures had been used; and (3) they included at least 100 PDs performed at centers handling at least 10 procedures a year, to avoid any bias associated with limited experience. Although a minimum of 10 PDs/year is no longer enough to define a center as "highvolume" [3], this threshold was retained to avoid discrepancies between the two periods considered in the review (1990-2015 and 2016-2018).…”

“…Pancreatoduodenectomy (PD) has become safer over the past two decades, but POPF and its severe complications are still responsible for a significant perioperative mortality rate (approximately 1%) and quite a high morbidity rate (66-73%) [1][2][3].…”

Seasonal variations in pancreatic surgery outcome A retrospective time-trend analysis of 2748 Whipple procedures

“…A "benchmark case" was defined as a standard Whipple procedure in a surgically fit patient in which the best achievable results are expected. Specific criteria to define a benchmark case have been recently identified in a multicentric international study [24].…”