Journal of Gastrointestinal Surgery

, Volume 16, Issue 1, pp 89–103 | Cite as

A Root-Cause Analysis of Mortality Following Major Pancreatectomy

  • Charles Mahlon VollmerJr.Email author
  • Norberto Sanchez
  • Stephen Gondek
  • John McAuliffe
  • Tara S. Kent
  • John D. Christein
  • Mark P. Callery
  • The Pancreatic Surgery Mortality Study Group
2011 SSAT Plenary Presentation



Although mortality rates from pancreatectomy have decreased worldwide, death remains an infrequent but profound event at an individual practice level. Root-cause analysis is a retrospective method commonly employed to understand adverse events. We evaluate whether emerging mortality risk assessment tools sufficiently predict and account for actual clinical events that are often identified by root-cause analysis.


We assembled a Pancreatic Surgery Mortality Study Group comprised of 36 pancreatic surgeons from 15 institutions in 4 countries. Mortalities after pancreatectomy (30 and 90 days) were accrued from 2000 to 2010. For root-cause analysis, each surgeon “deconstructed” the clinical events preceding a death to determine cause. We next tested whether mortality risk assessment tools (ASA, POSSUM, Charlson, SOAR, and NSQIP) could predict those patients who would die (n = 218) and compared their prognostic accuracy against a cohort of resections in which no patient died (n = 1,177).


Two hundred eighteen deaths (184 Whipple’s resection, 18 distal pancreatectomies, and 16 total pancreatectomies) were identified from 11,559 pancreatectomies performed by surgeons whose experience averaged 14.5 years. Overall 30- and 90-day mortalities were 0.96% and 1.89%, respectively. Individual surgeon rates ranged from 0% to 4.7%. Only 5 patients died intraoperatively, while the other 213 succumbed at a median of 29 days. Mean patient age was 70 years old (38% were >75 years old). Malignancy was the indication in 90% of cases, mostly pancreatic cancer (57%). Median operative time was 365 min and estimated blood loss was 700 cc (range, 100–16,000 cc). Vascular repair or multivisceral resections were required for 19.7% and 15.1%, respectively. Seventy-seven percent had a variety of major complications before death. Eighty-seven percent required intensive care unit care, 55% were transfused, and 35% were reoperated upon. Fifty percent died during the index admission, while another 11% died after a readmission. Almost half (n = 107) expired between 31 and 90 days. Only 11% had autopsies. Operation-related complications contributed to 40% of deaths, with pancreatic fistula being the most evident (14%). Technical errors (21%) and poor patient selection (15%) were cited by surgeons. Of deaths, 5.5% had associated cancer progression—all occurring between 31 and 90 days. Even after root-cause scrutiny, the ultimate cause of death could not be determined for a quarter of the patients—most often between 31 and 90 days. While assorted risk models predicted mortality with variable discrimination from nonmortalities, they consistently underestimated the actual mortality events we report.


Root-cause analysis suggests that risk prediction should include, if not emphasize, operative factors related to pancreatectomy. While risk models can distinguish between mortalities and nonmortalities in a collective fashion, they vastly miscalculate the actual chance of death on an individual basis. This study reveals the contributions of both comorbidities and aggressive surgical decisions to mortality.


Mortality Death Outcomes Root-cause analysis Pancreatectomy Whipple’s resection Risk prediction 



The authors would like to acknowledge the hard work of the following people who accrued data for this project: Carolyn Phillips (Washington University of St. Louis), Karen Parks, BS (University of Alabama School of Medicine), and Minna Lee, MD (Columbia University School of Medicine). Finally, we acknowledge the useful collaboration of Dr. David Greenblatt, Dr. Kaytlin Kelly, Dr. Sharon Weber, and Mr. Todd Hanson from the University of Wisconsin regarding the use of the ACS-NSQIP risk prediction tool they developed. Finally, we appreciate the contribution of Dr. Jennifer Tseng (University of Massachusetts) for her insight into surgical risk scoring systems and pancreatic surgical mortality.


  1. 1.
    Hunt VC, Budd JW. Transduodenal resection of the ampulla of Vater for carcinoma of the distal end of the common duct with restoration of continuity of the common and pancreatic ducts with the duodenum. SG&O 1935; 61:651–661.Google Scholar
  2. 2.
    Howard JM. Pancreatico-duodenectomy: forty-one consecutive Whipple resections without an operative mortality. Ann Surg. 1968 Oct;168(4):629–40.PubMedCrossRefGoogle Scholar
  3. 3.
    Cameron JL, Pitt HA, Yeo CJ, Lillemoe KD, Kaufman HS, Coleman J.One hundred and forty-five consecutive pancreaticoduodenectomies without mortality.Ann Surg. 1993 May;217(5):430–5.PubMedCrossRefGoogle Scholar
  4. 4.
    Crile G Jr. The advantages of bypass operations over radical pancreaticoduodenectomy in the treatment of pancreatic cancer. SG&O 1970; 130:1049–1053.Google Scholar
  5. 5.
    Crist DW, Sitzman JV, Cameron JL. Improved hospital morbidity, mortality, and survival after the Whipple procedure. Ann Surg 1987; 206:358–365.PubMedCrossRefGoogle Scholar
  6. 6.
    Trede M, Schwall G, Saeger H. Survival after pancreaticoduodenectomy. Ann Surg 1990; 211:447–458.PubMedCrossRefGoogle Scholar
  7. 7.
    Cameron JL, Crist DW, Sitzmann JV, et al. Factors influencing survival following pancreaticoduodenectomy for pancreatic cancer. Am J Surg 1991; 161:120–125.PubMedCrossRefGoogle Scholar
  8. 8.
    McPhee JT, Hill JS, Whalen GF, Zayaruzny M, Litwin DE, Sullivan ME, Anderson FA, Tseng JF. Perioperative mortality for pancreatectomy: a national perspective. Ann Surg. 2007 Aug;246(2):246–53.PubMedCrossRefGoogle Scholar
  9. 9.
    Eppsteiner RW, Csikesz NG, McPhee JT, Tseng JF, Shah SA. Surgeon volume impacts hospital mortality for pancreatic resection. Ann Surg. 2009 Apr;249(4):635–40.PubMedCrossRefGoogle Scholar
  10. 10.
    Hill JS, McPhee JT, Whalen GF, Sullivan ME, Warshaw AL, Tseng JF. In-hospital mortality after pancreatic resection for chronic pancreatitis: population-based estimates from the nationwide inpatient sample. J Am Coll Surg. 2009 Oct;209(4):468–76. Epub 2009 Aug 20.PubMedCrossRefGoogle Scholar
  11. 11.
    Murphy MM, Knaus WJ 2nd, Ng SC, Hill JS, McPhee JT, Shah SA, Tseng JF. Total pancreatectomy: a national study. HPB (Oxford). 2009 Sep;11(6):476–82.CrossRefGoogle Scholar
  12. 12.
    Sohn TA, Yeo CJ, Cameron JL, Koniaris L, Kaushal S, Abrams RA, Sauter PK, Coleman J, Hruban RH, Lillemoe KD. Resected adenocarcinoma of the pancreas-616 patients: results, outcomes, and prognostic indicators. J Gastrointest Surg. 2000 Nov–Dec;4(6):567–79.PubMedCrossRefGoogle Scholar
  13. 13.
    Fernández-del Castillo C, Rattner DW, Warshaw AL. Standards for pancreatic resection in the 1990s. Arch Surg. 1995 Mar;130(3):295–9; discussion 299–300.PubMedCrossRefGoogle Scholar
  14. 14.
    Vollmer, C.M., Jr., Pratt, W., Vanounou, T., et al., Quality assessment in high-acuity surgery: volume and mortality are not enough. Arch Surg, 2007. 142(4): p. 371–80.PubMedCrossRefGoogle Scholar
  15. 15.
    Birkmeyer JD, SiewersAE, Finlayson EVA, et al. Hospital volume and surgical mortiality in the United States. N Engl J Med 2002; 346:1128–1137.PubMedCrossRefGoogle Scholar
  16. 16.
    Carroll JE, Smith JK, Simons JP, Murphy MM, Ng SC, Shah SA, Zhou Z, Tseng JF. Redefining mortality after pancreatic cancer resection. J Gastrointest Surg. 2010 Nov;14(11):1701–8. Epub 2010 Sep 16.PubMedCrossRefGoogle Scholar
  17. 17.
    Mullen JT, Ribero D, Reddy SK, Donadon M, Zorzi D, Gautam S, Abdalla EK, Curley SA, Capussotti L, Clary BM, Vauthey JN. Hepatic insufficiency and mortality in 1,059 noncirrhotic patients undergoing major hepatectomy. J Am Coll Surg. 2007 May;204(5):854–62.PubMedCrossRefGoogle Scholar
  18. 18.
    Peleg O, Givot N, Halamish-Shani T, Taicher S. Wrong tooth extraction: root cause analysis. Quintessence Int 2010;41(10):869–72.PubMedGoogle Scholar
  19. 19.
    Perkins JD, Levy AE, Duncan JB, Carithers RL. Using root cause analysis to improve survival in a liver transplant program. J Surg Res 2005;129(1):6–16.PubMedCrossRefGoogle Scholar
  20. 20.
    Ahmed AR, Miskovic D, Vijayaseelan T, O’Malley W, Hanna GB. Root cause analysis of internal hernia and Roux limb compression after laparoscopic Roux-en-Y gastric bypass using observational clinical human reliability assessment. Surg Obes Relat Dis 2011 Jan 14. doi: 10.1016/j.soard.2010.12.009.
  21. 21.
    Copeland GP, Jones D, and Walters M. POSSUM: a scoring system for surgical audit. Br J Surg 1991; 78:356–360.CrossRefGoogle Scholar
  22. 22.
    Pratt, W., Joseph, S., Callery, M.P., et al., POSSUM accurately predicts morbidity for pancreatic resection. Surgery, 2008. 143(1): p. 8–19.PubMedCrossRefGoogle Scholar
  23. 23.
    Hill JS, Zhou Z, Simons JP, Ng SC, McDade TP, Whalen GF, Tseng JF. A simple risk score to predict in-hospital mortality after pancreatic resection for cancer. Ann Surg Oncol. 2010 Jul;17(7):1802–7.PubMedCrossRefGoogle Scholar
  24. 24.
    Greenblatt DY, Kelly KJ, Rajamanickam V, Wan Y, Hanson T, Rettammel R, Winslow ER, Cho CS, Weber SM. Preoperative Factors Predict Perioperative Morbidity and Mortality After Pancreaticoduodenectomy. Ann Surg Oncol. 2011 Aug;18(8):2126–35. Feb 20. doi: 10.1245/s10434-011-1594-6.Google Scholar
  25. 25.
    Kelly KJ, Greenblatt DY, Wan Y, Rettammel RJ, Winslow E, Cho CS, Weber SM. Risk stratification for distal pancreatectomy utilizing ACS-NSQIP: preoperative factors predict morbidity and mortality. J Gastrointest Surg. 2011 Feb;15(2):250–9.PubMedCrossRefGoogle Scholar
  26. 26.
    Dindo D, Demartines N, and Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004; 240:205–213.PubMedCrossRefGoogle Scholar
  27. 27.
    Pratt W, Maithel SK, Vanounou T, Huang Z, Callery MP, Vollmer CM. Clinical and economic validation of the International Study Group of Pancreatic Fistula (ISGPF) Classification Scheme. Annals of Surgery 2007 Mar.; 245(3):443–451.PubMedCrossRefGoogle Scholar
  28. 28.
    Kamath PS, Wiesner RH, Malinchoc M, Kremers W, Therneau TM, Kosberg CL, D’Amico G, Dickson ER, and Kim WR. A Model to Predict Survival in Patients With End-Stage Liver Disease Hepatology 2001; 33:464–470.PubMedCrossRefGoogle Scholar
  29. 29.
    New Classification of Physical Status. Anestesiology 1963;24:111Google Scholar
  30. 30.
    Pratt WB, Callery MP, and Vollmer CM. Risk prediction for Development of Pancreatic fistula Using the ISGPF Classification Scheme. World J Surg 2008; 32:419–428.PubMedCrossRefGoogle Scholar
  31. 31.
    Pratt, W., Callery, M.P., and Vollmer, C.M., Jr., Optimal surgical performance attenuates physiologic risk in high-acuity operations. J Am Coll Surg, 2008. 207(5): p. 717–30.PubMedCrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2011

Authors and Affiliations

  • Charles Mahlon VollmerJr.
    • 1
    Email author
  • Norberto Sanchez
    • 1
  • Stephen Gondek
    • 1
  • John McAuliffe
    • 2
  • Tara S. Kent
    • 1
  • John D. Christein
    • 2
  • Mark P. Callery
    • 1
  • The Pancreatic Surgery Mortality Study Group
    • 3
  1. 1.Department of Surgery, Beth Israel Deaconess Medical CenterHarvard Medical SchoolBostonUSA
  2. 2.Department of Surgery, School of MedicineUniversity of Alabama at BirminghamBirminghamUSA
  3. 3.International, Multi-institutional ConsortiumBostonUSA

Personalised recommendations