Rates of Complications and Death After Pancreaticoduodenectomy: Risk Factors and the Impact of Hospital Volume

Abstract

ObjectiveTo perform a two-part study of pancreaticoduodenectomy in the Netherlands, focusing on the effects of risk factors on outcomes in a single high-volume hospital and the effect of hospital volume on outcomes. Summary Background DataHospital volume and surgeon caseload can be related to the rates of complications and death, and the influence of risk factors can be volume-dependent. Provision of regionalized care should take this into account. MethodsIn part A, a single-institution database on 300 consecutive patients undergoing pancreaticoduodenectomy was divided into two periods with similar numbers of patients. Overall complications, deaths, hospital stay, and risk factors were analyzed in the two periods and compared with an historical reference group. In part B, Netherlands medical registry data on age and postoperative death of patients who underwent partial pancreaticoduodenectomy from 1994 to 1998 were analyzed for the influence of hospital volume on death. ResultsBetween the time periods, the institutional death rate decreased from 4.9% to 0.7%, the complication rate from 60% to 41%. Median hospital stay decreased from 24 to 15 days. The death rate was not related to patient age and did not differ between surgeons. Serum creatinine levels, need for blood transfusion, and period of resection were independent risk factors for complications.The death rate after pancreaticoduodenectomy in the Netherlands was 12.6% in 1994 and 10.1% in 1998; it was greater in patients older than age 65. During the 5-year period, 40% of the procedures were performed in hospitals performing fewer than five resections per year, and the death rate was greater than in hospitals performing more than 25 resections per year. ConclusionsThe overall death rate after pancreaticoduodenectomy did not decrease significantly during the period, and it was greater in low-volume hospitals and older patients. The lower death and complication rates in high-volume hospitals, including the singlecenter outcomes, were similar to those reported in other countries and may be due to better prevention and management of complications. Pancreaticoduodenectomy should be performed in centers with sufficient experience and resources for support.In the past, pancreaticoduodenectomy has been associated with a high rate of complications (40 -60%) and a high death rate (up to 20%). Combined with a dismal prognosis, in particular for patients with pancreatic carcinoma, this led to a nihilistic approach by some clinicians.1 In experienced centers, death rates have decreased dramatically, 2-6 which has encouraged other surgeons to perform pancreatic resections in nonspecialized units. The complication and death rates of surgery depend on many variables, including the presence of malignancy, the severity of jaundice, nutritional status, infection, and impaired renal function. 7,8 These factors have allowed better patient selection. In parallel, several reports since 1995 have highlighted the influence of hospital volume on hospital death.

Benefits of specialisation in the management of pancreatic cancer: results of a Scottish population-based study

“…Several studies (Edge et al, 1993;Gordon et al, 1995;Lieberman et al, 1995;Neoptolemos et al, 1997;Gouma et al, 2000;Garden, 2001;NHS Executive, 2001;Rosemurgy et al, 2001;Teisberg et al, 2001;Birkmeyer et al, 2002;Halm et al, 2002;Bachmann et al, 2003) have suggested that specialisation in this field may yield better results in terms of postoperative mortality, surgical complications, and longer term survival, although other studies have not found this relationship (Wade et al, , 1996, and the possibility of publication bias must be considered. Some previous studies are subject to the criticism that in-hospital mortality was used as an outcome, despite the fact that length of stay may be lower in patients treated by specialist pancreatic surgeons or hospitals with higher caseloads (Imperato et al, 1996;Sosa et al, 1998;Gordon et al, 1999;Simunovic et al, 1999;Rosemurgy et al, 2001).…”

“…Furthermore, it has recently been suggested that there may be some scope for improvement in survival figures in the UK (NHS Executive, 2001;Garden, 2001). This guarded optimism is based on accumulating evidence that the concentration of treatment activity among fewer high volume hospitals and/ or surgeons (as a proxy for specialisation) may lead to improved outcomes for patients with pancreatic cancer (Edge et al, 1993;Gordon et al, 1995;Lieberman et al, 1995;Neoptolemos et al, 1997;Gouma et al, 2000;NHS Executive, 2001;Garden, 2001;Rosemurgy et al, 2001;Teisberg et al, 2001;Halm et al, 2002;Birkmeyer et al, 2002;Bachmann et al, 2003). Many of the studies report reduced postoperative morbidity and mortality rates, and shorter postoperative hospital stays following resection of pancreatic cancer, although few have analysed long-term outcome.…”

Survival results of a multicentre phase II study to evaluate D2 gastrectomy for gastric cancer

“…Pancreaticoduodenectomy for pancreatic cancer or radical oesophagectomy for oesophageal cancer are more surgically aggressive procedures than D2 gastrectomy and are recommended to be performed exclusively in specialised centres. They do not carry a risk of hospital mortality of over 10% in such centres (Altorki and Skinner, 1997;Gordon et al, 1998;Bottger and Junginger, 1999;Lerut et al, 1999;Tsiotos et al, 1999;Gouma et al, 2000;Karl et al, 2000). Postoperative mortality of over 10% is no longer acceptable in any kind of cancer surgery.…”

Analysis of procedure-related complications after pancreatodoudenectomy

“…The operation classically involves removal of the pylorus and antrum; however recently, surgeons have used a pylorus-preserving Whipple procedure to lower the incidence of postgastrectomy symptoms, such as delayed gastric emptying. Both methods -the standard and the pylorus-preserving Whipple-have their advocates, but each method continues to have gastroparesis as a postoperative problem [4,10,[20][21]. In our study, 11 (8.7%) of 126 patients underwent PD complicated delayed gastric emptying after operation.…”

“…A recent study from Yeh et al [18], identified jaundice, creatinine clearance abnormality, and intraoperative blood loss as significant risk factors for leakage. Matsusue et al [19], found that One of the most common morbidities after PD is delayed gastric emptying with rates of 15-40% [20][21]. Advances in surgical skills and postoperative care have resulted in mortality rates of <5% [22][23].…”