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Lessons learned from 300 consecutive pancreaticoduodenectomies over a 25-year experience: the “safety net” improves the outcomes beyond surgeon skills

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Abstract

Pancreaticoduodenectomy (PD) is associated with high postoperative morbidity. The management of postoperative complications is paramount for reducing the mortality rate. The aim of this study was to evaluate the importance of surgical and hospital experience on outcomes by comparing postoperative results in three different hospitals with increasing resources for supporting the same surgical team. Patients data and surgical outcome of 300 consecutive patients undergoing PD were collected prospectively in the department database and divided into three periods (A = 1990–2000, B = 2001–March 2007, C = April 2007–2015). Pancreatico-jejunostomy was the procedure of choice between 1995 and 2004, and pancreatico-gastrostomy was performed afterwards. In the periods A, B and C, a total of 78, 85 and 137 PD were performed, respectively, and the number of PDs per year increased from 5 to 25. Between the three periods, the death rate (10.4 vs. 6 vs. 1.6%, p = 0.01) and intraoperative RBC transfusion rate (84.9 vs. 42.4 vs. 6.5%, p = 0.01) decreased significantly, whereas the vascular resection rate increased significantly (1.2 vs. 7 vs. 14.5, p < 0.002). Morbidity and reoperation rates did not change significantly between the three periods as well as operative time and median length of stay. Infectious complications and sepsis represented the most frequent major complication. Massive bleeding associated with uncontrolled pancreatic leak represented the major cause of morbidity and reoperation in the three periods, however, the relative mortality rate decreased significantly with no deaths in the last period. PD remains a challenging procedure with high morbidity and mortality rate. A multidisciplinary pancreatic team represents the “safety net” of pancreatic surgeon because it improves the results beyond the surgeon skills and experience.

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References

  1. Whipple A, Parsons WB, Mullins CR (1935) Treatment of carcinoma of the ampulla of Vater. Ann Surg 102:763–779 (PMID: 17856666)

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. Whipple A (1963) A reminiscence: pancreaticoduodenectomy. Rev Surg 20:221–255 (PMID: 14000261)

    CAS  PubMed  Google Scholar 

  3. Lieberman MD, Kilburn H, Lindsey M, Brennan MF (1995) Relation of perioperative deaths to hospital volume among patients undergoing pancreatic resection for malignancy. Ann Surg 222:638–645 (PMID: 7487211)

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  4. Birkmeyer JD, Finlayson SR, Tosteson AN, Sharp SM, Warshaw AL, Fisher ES (1999) Effect of hospital volume on in-hospital mortality with pancreaticoduodenectomy. Surgery 125:250–256 (PMID: 10076608)

    Article  CAS  PubMed  Google Scholar 

  5. Gouma DJ, van Geenen RC, van Gulik TM, de Haan RJ, de Wit LT, Busch OR, Obertop H (2000) Rates of complications and death after pancreaticoduodenectomy: risk factors and the impact of hospital volume. Ann Surg 232:786–795 (PMID: 11088073)

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Neoptolemos JP, Russell RC, Bramhall S, Theis B (1997) Low mortality following resection for pancreatic and periampullary tumours in 1026 patients: UK survey of specialist pancreatic units. UK Pancreatic Cancer Group. Br J Surg 84:1370–1376 (PMID: 9361591)

    Article  CAS  PubMed  Google Scholar 

  7. Coe TM, Fong ZV, Wilson SE, Talamini MA, Lillemoe KD, Chang DC (2015) Outcomes improvement is not continuous along the learning curve for pancreaticoduodenectomy at the hospital level. J Gastrointest Surg 19:2132–2137. doi:10.1007/s11605-015-2967-0 (PMID: 26438484)

    Article  PubMed  PubMed Central  Google Scholar 

  8. Addeo P, Delpero JR, Paye F, Oussoultzoglou E, Fuchshuber PR, Sauvanet A, Sa Cunha A, Le Treut YP, Adham M, Mabrut JY, Chiche L, Bachellier P, French Surgical Association (AFC) (2014) Pancreatic fistula after a pancreaticoduodenectomy for ductal adenocarcinoma and its association with morbidity: a multicentre study of the French Surgical Association. HPB (Oxford) 16:46–55. doi:10.1111/hpb.12063 (PMID: 23461663)

    Article  Google Scholar 

  9. Pecorelli N, Balzano G, Capretti G, Zerbi A, Di Carlo V, Braga M (2012) Effect of surgeon volume on outcome following pancreaticoduodenectomy in a high-volume hospital. J Gastrointest Surg 16:518–523. doi:10.1007/s11605-011-1777-2 (PMID: 2208 3531)

    Article  PubMed  Google Scholar 

  10. Lygidakis NJ (1996) Reconstruction of alimentary continuity after subtotal duodenopancreatectomy. Hepatogastroenterology 43:971–979 (PMID: 8884323)

    CAS  PubMed  Google Scholar 

  11. Munoz-Bongrand N, Sauvanet A, Denys A, Sibert A, Vilgrain V, Belghiti J (2004) Conservative management of pancreatic fistula after pancreaticoduodenectomy with pancreaticogastrostomy. J Am Coll Surg 199:198–203. doi:10.1016/j.jamcollsurg.2004.03.015 (PMID: 15275873)

    Article  PubMed  Google Scholar 

  12. DeOliveira ML, Winter JM, Schafer M, Cunningham SC, Cameron JL, Yeo CJ, Clavien PA (2006) Assessment of complications after pancreatic surgery: a novel grading system applied to 633 patients undergoing pancreaticoduodenectomy. Ann Surg 244:931–937. doi:10.1097/01.sla.0000246856.03918.9 (PMID: 17122618)

    Article  PubMed  PubMed Central  Google Scholar 

  13. Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, Neoptolemos J, Sarr M, Traverso W, Buchler M, International Study Group on Pancreatic Fistula Definition (2005) Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 138:8–13. doi:10.1016/j.surg.2005.05.001 (PMID: 16003309)

    Article  PubMed  Google Scholar 

  14. Schmidt CM, Turrini O, Parikh P, House MG, Zyromski NJ, Nakeeb A, Howard TJ, Pitt HA, Lillemoe KD (2010) Effect of hospital volume, surgeon experience, and surgeon volume on patient outcomes after pancreaticoduodenectomy: a single-institution experience. Arch Surg 145:634–640. doi:10.1001/archsurg.2010.118 (PMID: 20644125)

    Article  PubMed  Google Scholar 

  15. Böttger TC, Junginger T (1999) Factors influencing morbidity and mortality after pancreaticoduodenectomy: critical analysis of 221 resections. World J Surg 23:164–171 (PMID: 9880426)

    Article  PubMed  Google Scholar 

  16. Meniconi RL, Ettorre GM, Vennarecci G, Lepiane P, Colasanti M, Laurenzi A, Colace L, Santoro R (2013) Use of cold-stored vein allografts for venous reconstruction during pancreaticoduodenectomy. J Gastrointest Surg 17:1233–1239. doi:10.1007/s11605-013-2201-x (PMID: 23615805)

    Article  PubMed  Google Scholar 

  17. Ball CG, Dixon E, Vollmer CM, Howard TJ (2015) The view from 10,000 procedures: technical tips and wisdom from master pancreatic surgeons to avoid hemorrhage during pancreaticoduodenectomy. BMC Surg 15:122. doi:10.1186/s12893-015-0109-y (PMID: 26608343)

    Article  PubMed  PubMed Central  Google Scholar 

  18. Uzunoglu FG, Reeh M, Vettorazzi E, Ruschke T, Hannah P, Nentwich MF, Vashist YK, Bogoevski D, König A, Janot M, Gavazzi F, Zerbi A, Todaro V, Malleo G, Uhl W, Montorsi M, Bassi C, Izbicki JR, Bockhorn M (2014) Preoperative Pancreatic Resection (PREPARE) score: a prospective multicenter-based morbidity risk score. Ann Surg 260:857–863. doi:10.1097/SLA.0000000000000946 (PMID: 25243549)

    Article  PubMed  Google Scholar 

  19. Braga M, Capretti G, Pecorelli N, Balzano G, Doglioni C, Ariotti R, Di Carlo V (2011) A prognostic score to predict major complications after pancreaticoduodenectomy. Ann Surg 254:702–707. doi:10.1097/SLA.0b013e31823598fb (PMID: 22042466)

    Article  PubMed  Google Scholar 

  20. van Berge Henegouwen MI, De Wit LT, Van Gulik TM, Obertop H, Gouma DJ (1997) Incidence, risk factors, and treatment of pancreatic leakage after pancreaticoduodenectomy: drainage versus resection of the pancreatic remnant. J Am Coll Surg 185:18–24 (PMID: 9208956)

    Article  PubMed  Google Scholar 

  21. Joliat GR, Petermann D, Demartines N, Schäfer M (2015) Prediction of complications after pancreaticoduodenectomy: validation of a postoperative complication score. Pancreas 44:1323–1328. doi:10.1097/MPA.0000000000000399 (PMID: 26465955)

    Article  PubMed  Google Scholar 

  22. Pillai SA, Palaniappan R, Pichaimuthu A, Rajendran KK, Sathyanesan J, Govindhan M (2014) Feasibility of implementing fast-track surgery in pancreaticoduodenectomy with pancreaticogastrostomy for reconstruction—a prospective cohort study with historical control. Int J Surg 12:1005–1009. doi:10.1016/j.ijsu.2014.07.002 (PMID: 25014648)

    Article  PubMed  Google Scholar 

  23. Lassen K, Coolsen MM, Slim K, Carli F, de Aguilar-Nascimento JE, Schäfer M, Parks RW, Fearon KC, Lobo DN, Demartines N, Braga M, Ljungqvist O, Dejong CH, ERAS® Society, European Society for Clinical Nutrition and Metabolism, International Association for Surgical Metabolism and Nutrition (2012) Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clin Nutr 31:817–830. doi:10.1016/j.clnu.2012.08.011 (PMID: 23079762)

    Article  PubMed  Google Scholar 

  24. Braga M, Pecorelli N, Ariotti R, Capretti G, Greco M, Balzano G, Castoldi R, Beretta L (2014) Enhanced recovery after surgery pathway in patients undergoing pancreaticoduodenectomy. World J Surg 38:2960–2966. doi:10.1007/s00268-014-2653-5 (PMID: 24870390)

    Article  PubMed  Google Scholar 

  25. Rush TJ (2001) The role of the infectious disease specialist in pancreatic surgery. Surg Clin North Am 81:647–650 (PMID: 11459278)

    Article  CAS  PubMed  Google Scholar 

  26. Toomey PG, Teta AF, Patel KD, Ross SB, Rosemurgy AS (2016) High-volume surgeons vs high-volume hospitals: are best outcomes more due to who or where? Am J Surg 211:59–63. doi:10.1016/j.amjsurg.2015.08.021 (PMID: 26542187)

    Article  PubMed  Google Scholar 

  27. Bassi C, Falconi M, Molinari E, Salvia R, Butturini G, Sartori N, Mantovani W, Pederzoli P (2005) Reconstruction by pancreaticojejunostomy versus pancreaticogastrostomy following pancreatectomy: results of a comparative study. Ann Surg 242:767–771 (PMID: 16327486)

    Article  PubMed  PubMed Central  Google Scholar 

  28. Oussoultzoglou E, Bachellier P, Bigourdan JM, Weber JC, Nakano H, Jaeck D (2004) Pancreaticogastrostomy decreased relaparotomy caused by pancreatic fistula after pancreaticoduodenectomy compared with pancreaticojejunostomy. Arch Surg 139:327–335. doi:10.1001/archsurg.139.3.327 (PMID: 15006893)

    Article  PubMed  Google Scholar 

  29. McKay A, Mackenzie S, Sutherland FR, Bathe OF, Doig C, Dort J, Vollmer CM Jr, Dixon E (2006) Meta-analysis of pancreaticojejunostomy versus pancreaticogastrostomy reconstruction after pancreaticoduodenectomy. Br J Surg 93:929–936. doi:10.1002/bjs.5407 (PMID: 16845693)

    Article  CAS  PubMed  Google Scholar 

  30. Santoro R, Carlini M, Carboni F, Nicolas C, Santoro E (2003) Delayed massive arterial hemorrhage after pancreaticoduodenectomy for cancer. Management of a life-threatening complication. Hepatogastroenterology 50:2199–2204 (PMID: 14696498)

    PubMed  Google Scholar 

  31. Chen JF, Xu SF, Zhao W, Tian YH, Gong L, Yuan WS, Dong JH (2015) Diagnostic and therapeutic strategies to manage post-pancreaticoduodenectomy hemorrhage. World J Surg 39:509–515. doi:10.1007/s00268-014-2809-3 (PMID: 25287917)

    Article  PubMed  Google Scholar 

  32. Topal B, Fieuws S, Aerts R, Weerts J, Feryn T, Roeyen G, Bertrand C, Hubert C, Janssens M, Closset J, Belgian Section of Hepatobiliary and Pancreatic Surgery (2013) Pancreaticojejunostomy versus pancreaticogastrostomy reconstruction after pancreaticoduodenectomy for pancreatic or periampullary tumours: a multicentre randomised trial. Lancet Oncol 14:655–662. doi:10.1016/S1470-2045(13)70126-8 (PMID: 23643139)

    Article  PubMed  Google Scholar 

  33. Menahem B, Guittet L, Mulliri A, Alves A, Lubrano J (2015) Pancreaticogastrostomy is superior to pancreaticojejunostomy for prevention of pancreatic fistula after pancreaticoduodenectomy: an updated meta-analysis of randomized controlled trials. Ann Surg 261:882–887. doi:10.1097/SLA.0000000000000806 (PMID: 24979604)

    Article  PubMed  Google Scholar 

  34. Lee GC, Fong ZV, Ferrone CR, Thayer SP, Warshaw AL, Lillemoe KD, Fernández-del Castillo C (2014) High performing Whipple patients: factors associated with short length of stay after open pancreaticoduodenectomy. J Gastrointest Surg 18:1760–1769. doi:10.1007/s11605-014-2604-3 (PMID: 25091843)

    Article  PubMed  Google Scholar 

  35. Cameron JL, He J (2015) Two thousand consecutive pancreaticoduodenectomies. J Am Coll Surg 220:530–536. doi:10.1016/j.jamcollsurg.2014.12.031 (PMID: 25724606)

    Article  PubMed  Google Scholar 

  36. Sadot E, Brennan MF, Lee SY, Allen PJ, Gönen M, Groeger JS, Peter Kingham T, D’Angelica MI, DeMatteo RP, Jarnagin WR, Fong Y (2014) Readmission after pancreatic resection: causes and causality pattern. Ann Surg Oncol 21:4342–4350. doi:10.1245/s10434-014-3841-0 (PMID: 25047467)

    Article  PubMed  PubMed Central  Google Scholar 

  37. Sutton JM, Wilson GC, Wima K, Hoehn RS, Cutler Quillin R 3rd, Hanseman DJ, Paquette IM, Sussman JJ, Ahmad SA, Shah SA, Abbott DE (2015) Readmission after pancreaticoduodenectomy: the influence of the volume effect beyond mortality. Ann Surg Oncol 22:3785–3792. doi:10.1245/s10434-015-4451-1 (PMID: 25840560)

    Article  PubMed  Google Scholar 

  38. Goodney PP, Stukel TA, Lucas FL, Finlayson EV, Birkmeyer JD (2003) Hospital volume, length of stay, and readmission rates in high-risk surgery. Ann Surg 238:161–167. doi:10.1097/01.SLA.0000081094.66659.c3 (PMID: 12894006)

    PubMed  PubMed Central  Google Scholar 

  39. Berwick DM, Hackbarth AD (2012) Eliminating waste in US health care. JAMA 307:1513–1516. doi:10.1001/jama.2012.362 (PMID: 22419800)

    Article  CAS  PubMed  Google Scholar 

  40. Joliat GR, Labgaa I, Petermann D, Hübner M, Griesser AC, Demartines N, Schäfer M (2015) Cost-benefit analysis of an enhanced recovery protocol for pancreaticoduodenectomy. Br J Surg 102:1676–1683. doi:10.1002/bjs.9957 (PMID: 26492489)

    Article  PubMed  Google Scholar 

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Acknowledgements

Other members of the Polo Ospedaliero Interaziendale Trapianti (P.O.I.T.) ‘‘Silvio Natoli’’ Multidisciplinary Group of Rome are M. Burocchi, A. Campanelli, A. Scotti, A. Laurenzi, S. Di Filippo, R. Lorusso, P. Mancini, A. Di Castro and E. Santoro, Department of General Surgery and Transplantation, A.O San Camillo-Forlanini General Hospital (SCF); M. Antonini, D. Busso, I. Caravella, C. Dantimi, R. Di Lorenzo, M. Fusetti, G. Garotto, F. Giansante, L. Marchioni, M. Maritti, S. Scarcia, G.V. Stazi, Anesthesiology and Intensive Care Unit, National Institute for Infectious Disease (INMI) ‘‘L. Spallanzani,’’; N. Petrosillo, A. Capone, F. Taglietti, G. Noto. Division of Systemic Infectious Disease and in Immunocompromised pazients, INMI; G. D’Offizi, R. Lionetti, L. Loiacono, M. Montalbano, A. Abdeaim, A. Rianda, L. Vincenzi, and U. Visco; Division of Hepatology and Infectious Disease, INMI; G. Cerasari, C. D’Ambrosio, L. Fondacaro, P. Guarascio, A. Pellicelli, R. Villani, Division of Hepatology, SCF; A. Tesi, C. Marrollo, P. Meddi, R. Mangiarotti, L. Giglio, C. Camastra, Division of Gastroenterology, SCF; E. Busi Rizzi, M. Cristofaro, F. Di Stefano, N. Fusco, F. Albarello and V. Schinina`, Imaging Division, INMI; M. Atzori, A. Cortese, P. Ialongo, G. Regine, and S. Pascoli, Imaging Division, SCF; Agresti, S. Giuliani, S. Minucci, M. Morucci, S. Pieri and P. Riu, Interventional Radiology, SCF; L.R. Grillo, Pathology Unit, SCF; A. Baiocchini and F. Del Nonno, Pathology Unit, INMI. We would like to thank F. Carboni, M. Carlini, M. Sacchi, M. D’Annibale, S. Canitano, F.L. Carpanese, M. Caterino, E. Forastiere, R. Kayal, P. Moricca, G. Pizzi, and G. Vallati for their valuable help at the Regina Elena Cancer Institute, Rome.

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  1. Department of General Surgery and Organ Transplantation, San Camillo-Forlanini Hospital, Circonvallazione Gianicolense 87, Rome, Italy

    Roberto Santoro, Roberto Luca Meniconi, Pasquale Lepiane, Giovanni Vennarecci, Gianluca Mascianà, Marco Colasanti, Eugenio Santoro & Giuseppe Maria Ettorre

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  1. Roberto Santoro
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  2. Roberto Luca Meniconi
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Correspondence to Roberto Luca Meniconi.

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Santoro, R., Meniconi, R.L., Lepiane, P. et al. Lessons learned from 300 consecutive pancreaticoduodenectomies over a 25-year experience: the “safety net” improves the outcomes beyond surgeon skills. Updates Surg 69, 451–460 (2017). https://doi.org/10.1007/s13304-017-0490-4

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