Annals of Surgical Oncology

, Volume 18, Issue 8, pp 2126–2135 | Cite as

Preoperative Factors Predict Perioperative Morbidity and Mortality After Pancreaticoduodenectomy

  • David Yu GreenblattEmail author
  • Kaitlyn J. Kelly
  • Victoria Rajamanickam
  • Yin Wan
  • Todd Hanson
  • Robert Rettammel
  • Emily R. Winslow
  • Clifford S. Cho
  • Sharon M. Weber
Healthcare Policy and Outcomes



Pancreaticoduodenectomy (PD) has long been associated with high rates of morbidity and mortality. The objective of this study was to identify preoperative risk factors for serious complications and mortality after PD and to construct a prediction tool to facilitate risk stratification prior to surgery.

Materials and Methods

Patients who underwent elective PD from 2005 to 2009 were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Multivariate logistic regression identified predictors of 30-day serious complications and mortality. A prediction tool was created and validated in a sample of 1254 patients.


Of 4945 patients who underwent PD, 1342 (27.1%) suffered a serious complication and 127 (2.6%) died within 30 days. The most frequent complications were sepsis (15.3%), surgical site infection (13.1%), and respiratory complications (9.5%). After adjusting for potential confounders, the significant predictors of morbidity included older age, male gender, overweight and obesity, dependent functional status, chronic obstructive pulmonary disease (COPD), steroid use, bleeding disorder, leukocytosis, elevated serum creatinine, and hypoalbuminemia. Significant predictors of 30-day mortality included COPD, hypertension, neoadjuvant radiation therapy, elevated serum creatinine, and hypoalbuminemia. Multivariable models were used to construct a preoperative risk stratification tool.


Preoperative factors are associated with perioperative outcomes after PD. The prediction tool estimates the probability of early morbidity and mortality for patients undergoing PD. The tool may be used to provide information for patient counseling during the informed consent process and to identify high-risk patients for the purpose of tailoring perioperative care.


Chronic Obstructive Pulmonary Disease Surgical Site Infection Pancreatic Fistula Prediction Tool Delay Gastric Emptying 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Whipple AO. Pancreaticoduodenectomy for islet carcinoma: a five-year follow-up. Ann Surg. 1945;121:847–52.PubMedCrossRefGoogle Scholar
  2. 2.
    Winter JM, Cameron JL, Campbell KA, Arnold MA, Chang DC, Coleman J, et al. 1423 pancreaticoduodenectomies for pancreatic cancer: a single-institution experience. J Gastrointest Surg. 2006;10:1199–210; discussion 1210–1.PubMedCrossRefGoogle Scholar
  3. 3.
    Raut CP, Tseng JF, Sun CC, Wang H, Wolff RA, Crane CH, et al. Impact of resection status on pattern of failure and survival after pancreaticoduodenectomy for pancreatic adenocarcinoma. Ann Surg. 2007;246:52–60.PubMedCrossRefGoogle Scholar
  4. 4.
    House MG, Fong Y, Arnaoutakis DJ, Sharma R, Winston CB, Protic M, et al. Preoperative predictors for complications after pancreaticoduodenectomy: impact of BMI and body fat distribution. J Gastrointest Surg. 2008;12:270–8.PubMedCrossRefGoogle Scholar
  5. 5.
    Gawande AA, Kwaan MR, Regenbogen SE, Lipsitz SA, Zinner MJ. An Apgar score for surgery. J Am Coll Surg. 2007;204:201–8.PubMedCrossRefGoogle Scholar
  6. 6.
    Pratt W, Joseph S, Callery MP, Vollmer CM, Jr. POSSUM accurately predicts morbidity for pancreatic resection. Surgery. 2008;143:8–19.PubMedCrossRefGoogle Scholar
  7. 7.
    Are C, Afuh C, Ravipati L, Sasson A, Ullrich F, Smith L. Preoperative nomogram to predict risk of perioperative mortality following pancreatic resections for malignancy. J Gastrointest Surg. 2009;13:2152–62.PubMedCrossRefGoogle Scholar
  8. 8.
    Hill JS, Zhou Z, Simons JP, Ng SC, McDade TP, Whalen GF, et al. A simple risk score to predict in-hospital mortality after pancreatic resection for cancer. Ann Surg Oncol. 2010;17:1802–7.PubMedCrossRefGoogle Scholar
  9. 9.
    American College of Surgeons National Surgical Quality Improvement Program website Accessed January 3, 2010.
  10. 10.
    World Health Organization. The International Classification of adult underweight, overweight and obesity according to body mass index Accessed January 3, 2010.
  11. 11.
    Hamilton BH, Ko CY, Richards K, Hall BL. Missing data in the American College of Surgeons National Surgical Quality Improvement Program are not missing at random: implications and potential impact on quality assessments. J Am Coll Surg. 2010;210:125–139.e2.PubMedCrossRefGoogle Scholar
  12. 12.
    Morris AM, Baldwin LM, Matthews B, Dominitz JA, Barlow WE, Dobie SA, et al. Reoperation as a quality indicator in colorectal surgery: a population-based analysis. Ann Surg. 2007;245:73–9.PubMedCrossRefGoogle Scholar
  13. 13.
    Finlayson EV, Birkmeyer JD, Stukel TA, Siewers AE, Lucas FL, Wennberg DE. Adjusting surgical mortality rates for patient comorbidities: more harm than good? Surgery. 2002;132:787–94.PubMedCrossRefGoogle Scholar
  14. 14.
    Billingsley KG, Hur K, Henderson WG, Daley J, Khuri SF, Bell RH, Jr. Outcome after pancreaticoduodenectomy for periampullary cancer: an analysis from the Veterans Affairs National Surgical Quality Improvement Program. J Gastrointest Surg. 2003;7:484–91.PubMedCrossRefGoogle Scholar
  15. 15.
    McPhee JT, Hill JS, Whalen GF, Zayaruzny M, Litwin DE, Sullivan ME, et al. Perioperative mortality for pancreatectomy: a national perspective. Ann Surg. 2007;246:246–53.PubMedCrossRefGoogle Scholar
  16. 16.
    Begg CB, Cramer LD, Hoskins WJ, Brennan MF. Impact of hospital volume on operative mortality for major cancer surgery. JAMA. 1998;280:1747–51.PubMedCrossRefGoogle Scholar
  17. 17.
    Birkmeyer JD, Finlayson SR, Tosteson AN, Sharp SM, Warshaw AL, Fisher ES. Effect of hospital volume on in-hospital mortality with pancreaticoduodenectomy. Surgery. 1999;125:250–6.PubMedCrossRefGoogle Scholar
  18. 18.
    Yeo CJ, Cameron JL, Sohn TA, Lillemoe KD, Pitt HA, Talamini MA, et al. Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes. Ann Surg. 1997;226:248–57; discussion 257–60.PubMedCrossRefGoogle Scholar
  19. 19.
    Balcom JH, 4th, Rattner DW, Warshaw AL, Chang Y, Fernandez-del Castillo C. Ten-year experience with 733 pancreatic resections: changing indications, older patients, and decreasing length of hospitalization. Arch Surg. 2001;136:391–8.PubMedCrossRefGoogle Scholar
  20. 20.
    Lin JW, Cameron JL, Yeo CJ, Riall TS, Lillemoe KD. Risk factors and outcomes in postpancreaticoduodenectomy pancreaticocutaneous fistula. J Gastrointest Surg. 2004;8:951–9.PubMedCrossRefGoogle Scholar
  21. 21.
    Grobmyer SR, Pieracci FM, Allen PJ, Brennan MF, Jaques DP. Defining morbidity after pancreaticoduodenectomy: use of a prospective complication grading system. J Am Coll Surg. 2007;204:356–64.PubMedCrossRefGoogle Scholar
  22. 22.
    Hashimoto Y, Traverso LW. Incidence of pancreatic anastomotic failure and delayed gastric emptying after pancreatoduodenectomy in 507 consecutive patients: use of a web-based calculator to improve homogeneity of definition. Surgery. 2010;147:503–15.PubMedCrossRefGoogle Scholar
  23. 23.
    Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery. 2005;138:8–13.PubMedCrossRefGoogle Scholar
  24. 24.
    Wente MN, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, et al. Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery. 2007;142:761–8.PubMedCrossRefGoogle Scholar
  25. 25.
    Pitt HA, Kilbane M, Strasberg SM, Pawlik TM, Dixon E, Zyromski NJ, et al. ACS-NSQIP has the potential to create an HPB-NSQIP option. HPB (Oxford). 2009;11:405–13.Google Scholar
  26. 26.
    Winter JM, Cameron JL, Yeo CJ, Alao B, Lillemoe KD, Campbell KA, et al. Biochemical markers predict morbidity and mortality after pancreaticoduodenectomy. J Am Coll Surg. 2007;204:1029–36; discussion 1037–8.PubMedCrossRefGoogle Scholar
  27. 27.
    Gouma DJ, van Geenen RC, van Gulik TM, de Haan RJ, de Wit LT, Busch OR, et al. Rates of complications and death after pancreaticoduodenectomy: risk factors and the impact of hospital volume. Ann Surg. 2000;232:786–95.PubMedCrossRefGoogle Scholar
  28. 28.
    DeOliveira ML, Winter JM, Schafer M, Cunningham SC, Cameron JL, Yeo CJ, et al. Assessment of complications after pancreatic surgery: a novel grading system applied to 633 patients undergoing pancreaticoduodenectomy. Ann Surg. 2006;244:931–7; discussion 937–9.PubMedCrossRefGoogle Scholar
  29. 29.
    Muscari F, Suc B, Kirzin S, Hay JM, Fourtanier G, Fingerhut A, et al. Risk factors for mortality and intra-abdominal complications after pancreatoduodenectomy: multivariate analysis in 300 patients. Surgery. 2006;139:591–8.PubMedCrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2011

Authors and Affiliations

  • David Yu Greenblatt
    • 1
    Email author
  • Kaitlyn J. Kelly
    • 1
  • Victoria Rajamanickam
    • 1
  • Yin Wan
    • 1
  • Todd Hanson
    • 1
  • Robert Rettammel
    • 1
  • Emily R. Winslow
    • 1
  • Clifford S. Cho
    • 1
  • Sharon M. Weber
    • 1
  1. 1.Department of SurgeryUniversity of WisconsinMadisonUSA

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