Novel Preoperative Patient-centered Surgical Wellness Program Impacts Length of Stay Following Pancreatectomy.

BACKGROUND/AIM: We created a novel, preoperative wellness program (WP) that promotes recovery. This study assessed its impact on patient outcomes after pancreatectomy. PATIENTS AND METHODS: Pancreatoduodenectomies (PD) and distal pancreatectomies (DP) performed from 2015 to 2018 were reviewed using our institutional NSQIP database. Patients in the WP had their medical conditions optimized and were provided with the following: chlorhexidine, topical mupirocin, incentive spirometer, and immune-nutrition supplements. RESULTS: Out of a total of 669 pancreatectomy patients (411 PD, 258 DP), 308 were enrolled in the WP (188 PD, 120 DP). In the PD subgroup, on multivariable analysis (MVA), the WP patients had shorter lengths of hospital stay (LOS) (12 vs. 10 days, p<0.001). On MVA, WP patients had less post-op transfusion (20 vs. 10%, p=0.027). For the combined groups on MVA, LOS continued to be significant (OR=0.89, 95%CI=0.82-0.97, p<0.007). CONCLUSION: A preoperative patient centered WP may reduce the length of stay.

Impact of Fellow Versus Resident Assistance on Outcomes Following Pancreatoduodenectomy.

BACKGROUND: Participation by surgical trainees in complex procedures is key to their development as future practicing surgeons. The impact of surgical fellows versus general surgery resident assistance on outcomes in pancreatoduodenectomy (PD) has not been well studied. The purpose of this study was to determine differences in patient outcomes based on level of surgical trainee. METHODS: Consecutive cases of PD (n = 254) were reviewed at a single high-volume institution over a 2-year period (July 2013-June 2015). Thirty-day outcomes were monitored through the American College of Surgeon's National Surgical Quality Improvement Program (NSQIP) and Quality In-Training Initiative. Patient outcomes were compared between PD assisted by general surgery residents versus hepatopancreatobiliary fellows. RESULTS: The hepatopancreatobiliary surgery fellows and general surgery residents participated in 109 and 145 PDs, respectively. The incidence of each individual postoperative complication (renal, infectious, pancreatectomy-specific, and cardiopulmonary), total morbidity, mortality, and failure to rescue were the same between groups. CONCLUSIONS: Patient operative outcomes were the same between fellow- and resident-assisted PD. These results suggest that hepatopancreatobiliary surgery fellows and general surgery residents should be offered the same opportunities to participate in complex general surgery procedures.

Peri-operative blood transfusion and operative time are quality indicators for pancreatoduodenectomy.

BACKGROUND: Minimization of blood loss during pancreatoduodenectomy requires careful surgical technique and specific preventative measures. Therefore, red blood cell (RBC) transfusions and operative time are potential surgical quality indicators. The aim of the present study was to compare peri-operative RBC transfusion and operative time with 30-day morbidity/mortality after pancreatoduodenectomy. METHODS: All pancreatoduodenectomies (2005 to 2008) were identified using the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP). RBC transfusions and operative time were correlated with 30-day morbidity/mortality. RESULTS: Pancreatoduodenectomy was completed in 4817 patients. RBC transfusions were given to 1559 (32%) patients (1-35 units). Overall morbidity and mortality rates were 37% and 3.0%, respectively. Overall 30-day morbidity increased in a stepwise manner with the number of RBC transfusions (R = 0.69, P < 0.01). Although RBC transfusions and operative times were not statistically linked (P = 0.87), longer operative times were linearly associated with increased 30-day morbidity (R = 0.79, P < 0.001) and mortality (R = 0.65, P < 0.01). Patients who were not transfused also displayed less morbidity (33%) and mortality (1.9%) (P < 0.05). DISCUSSION: Peri-operative RBC transfusion after pancreatoduodenectomy is linearly associated with 30-day morbidity. Longer operative time also correlates with increased morbidity and mortality. Therefore, blood transfusions and prolonged operative time should be considered quality indicators for pancreatoduodenectomy.

Pancreatic necrosectomy: North American mortality is much lower than expected.

BACKGROUND: The aim of this analysis was to explore the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to determine outcomes of patients undergoing debridement for pancreatic and peripancreatic necrosis. Single-institution series suggest that the mortality of patients undergoing pancreatic necrosectomy has improved but remains at 15% to 20%. But no national data have been available for patients with necrotizing pancreatitis. In 2007, a CPT code specific for debridement of pancreatic necrosis became available. STUDY DESIGN: The ACS-NSQIP Participant Use File was queried for all patients who had debridement of pancreatic and peripancreatic necrosis (CPT code 48105) from January 1, 2007, through December 31, 2007. Patient demographics, observed (O) and expected (E) morbidity and mortality, and indices (O/E) were evaluated. A multivariate stepwise logistic regression was performed to determine predictors of mortality. RESULTS: During this 12-month period, data were accumulated on 161 patients. The mean age was 54 years; 71% were male; and 75% were Caucasian. The mean body mass index was 30.3 kg/m(2); 29% had diabetes; and 11% abused alcohol. Forty-two percent were transferred to NSQIP hospitals from other facilities. Overall morbidity was 62%, and 30-day mortality was 6.8%, but morbidity and mortality indices were 0.86 and 0.33, respectively. Increased age and blood urea nitrogen were independent predictors of mortality. CONCLUSIONS: These data suggest that patients undergoing debridement for pancreatic and peripancreatic necrosis at ACS-NSQIP hospitals provide a new North American sample and have better than predicted outcomes. We concluded that ACS-NSQIP is a powerful tool to assess contemporary outcomes of uncommon, high-risk procedures.

ACS-NSQIP has the potential to create an HPB-NSQIP option.

BACKGROUND: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was started in 2004. Presently, 58% of the 198 hospitals participating in ACS-NSQIP are academic or teaching hospitals. In 2008, ACS-NSQIP initiated a number of changes and made risk-adjusted data available for use by participating hospitals. This analysis explores the ACS-NSQIP database for utility in developing hepato-pancreato-biliary (HPB) surgery-specific outcomes (HPB-NSQIP). METHODS: The ACS-NSQIP Participant Use File was queried for patient demographics and outcomes for 49 HPB operations from 1 January 2005 through 31 December 2007. The procedures included six hepatic, 16 pancreatic and 23 complex biliary operations. Four laparoscopic or open cholecystectomy operations were also studied. Risk-adjusted probabilities for morbidity and mortality were compared with observed rates for each operation. RESULTS: During this 36-month period, data were accumulated on 9723 patients who underwent major HPB surgery, as well as on 44,189 who received cholecystectomies. The major HPB operations included 2847 hepatic (29%), 5074 pancreatic (52%) and 1802 complex biliary (19%) procedures. Patients undergoing hepatic resections were more likely to have metastatic disease (42%) and recent chemotherapy (7%), whereas those undergoing complex biliary procedures were more likely to have significant weight loss (20%), diabetes (13%) and ascites (5%). Morbidity was high for hepatic, pancreatic and complex biliary operations (20.1%, 32.4% and 21.2%, respectively), whereas mortality was low (2.3%, 2.7% and 2.7%, respectively). Compared with laparoscopic cholecystectomy, the open operation was associated with higher rates of morbidity (19.2% vs. 6.0%) and mortality (2.5% vs. 0.3%). The ratios between observed and expected morbidity and mortality rates were <1.0 for hepatic, pancreatic and biliary operations. CONCLUSIONS: These data suggest that HPB operations performed at ACS-NSQIP hospitals have acceptable outcomes. However, the creation of an HPB-NSQIP has the potential to improve quality, provide risk-adjusted registries with HPB-specific data and facilitate multi-institutional clinical trials.