Variation in hospital mortality after pancreatoduodenectomy is related to failure to rescue rather than major complications: a nationwide audit

Abstract

Background: The 8th edition AJCC staging system for pancreatic cancer incorporated several significant changes. We sought to evaluate this staging system and assess its strengths and weaknesses relative to the 7th edition system. Methods: Using the Surveillance, Epidemiology and End Results (SEER) database (2004-2013), 8,960 patients undergoing surgical resection for non-metastatic pancreatic adenocarcinoma were identified. Overall survival was estimated using the Kaplan-Meier method and compared using log-rank tests. Concordance indices were calculated to evaluate the discriminatory power of both staging systems. Cox proportional hazards model were used to determine the impact of T and N classification on overall survival. Results: The concordance index for AJCC 8th staging system (0.60,CI95% 0.59-0.61) was comparable to that for the 7th AJCC staging system (0.59,CI95% 0.58-0.60). Stratified analyses for each N classification system demonstrated diminishing impact of T classification on overall survival with increasing nodal involvement. The corresponding concordance index for N0, N1 and N2 classifications were 0.58 (CI95%:0.55-0.60), 0.53 (CI95%:0.51-0.55), and 0.53 (CI95%:0.50-0.56) respectively. Conclusion: This is the first large-scale validation of the AJCC 8th edition staging system for pancreatic cancer. The revised system provides similar discrimination as compared to the 7th edition system. However, the 8th edition system allows finer stratification of patients with resected tumors according to extent of nodal involvement.

The role of repeated imaging in detecting complications in the post‐operative period following pancreaticoduodenectomy

“…The common cause for increased mortality following PD can be attributed to the delay in detection and management of major post‐operative complications 7 . Failure to rescue (FTR), defined as death of a patient due to a major post‐operative complication, has been identified as a key explanation for the varying mortality rates between hospitals in the setting of PD 7,32 .…”

“…While the incidence of post‐PD haemorrhage remains low compared to other post‐operative complications, it is a potentially life‐threatening complication particularly if it is not detected and treated in a timely manner 3 . With a varying incidence rate of 2%–13% in large series, 1–5 and an estimated mortality rate of 20%–50%, post‐PD haemorrhage contributes significantly to the post‐operative mortality and morbidity associated with PD 6,7 . In the post‐pancreatectomy setting, not all complications, including delayed post‐PD haemorrhage, are always preventable, so there has been a focus on the timely recognition of these complications to ensure early and definitive management to improve patient outcomes 8 .…”

“…In the post‐pancreatectomy setting, not all complications, including delayed post‐PD haemorrhage, are always preventable, so there has been a focus on the timely recognition of these complications to ensure early and definitive management to improve patient outcomes 8 . Failure to rescue (FTR), defined as death of a patient due to a major post‐operative complication, has been well established in the literature as a substantial contributing factor in the varying mortality rates in the setting of pancreatectomies 7 . As a result, reducing the FTR rate has become a priority and key target for quality improvement in pancreatic surgery 7,8 .…”

“…Failure to rescue (FTR), defined as death of a patient due to a major post‐operative complication, has been well established in the literature as a substantial contributing factor in the varying mortality rates in the setting of pancreatectomies 7 . As a result, reducing the FTR rate has become a priority and key target for quality improvement in pancreatic surgery 7,8 . Multiphase computed tomography (CT) imaging is the modality of choice to diagnose complications such as post‐PD haemorrhage.…”

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

“…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].…”