A Root-Cause Analysis of Mortality Following Major Pancreatectomy
- 842 Downloads
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.
KeywordsMortality 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.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
- 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
- 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.
- 29.New Classification of Physical Status. Anestesiology 1963;24:111Google Scholar