Background & Aims Treatment of patients with necrotizing pancreatitis has become more conservative and less invasive, but there are few data from prospective studies to support the efficacy of this ...change. We performed a prospective multicenter study of treatment outcomes among patients with necrotizing pancreatitis. Methods We collected data from 639 consecutive patients with necrotizing pancreatitis, from 2004 to 2008, treated at 21 Dutch hospitals. Data were analyzed for disease severity, interventions (radiologic, endoscopic, surgical), and outcome. Results Overall mortality was 15% (n = 93). Organ failure occurred in 240 patients (38%), with 35% mortality. Treatment was conservative in 397 patients (62%), with 7% mortality. An intervention was performed in 242 patients (38%), with 27% mortality; this included early emergency laparotomy in 32 patients (5%), with 78% mortality. Patients with longer times between admission and intervention had lower mortality: 0 to 14 days, 56%; 14 to 29 days, 26%; and >29 days, 15% ( P < .001). A total of 208 patients (33%) received interventions for infected necrosis, with 19% mortality. Catheter drainage was most often performed as the first intervention (63% of cases), without additional necrosectomy in 35% of patients. Primary catheter drainage had fewer complications than primary necrosectomy (42% vs 64%, P = .003). Patients with pancreatic parenchymal necrosis (n = 324), compared with patients with only peripancreatic necrosis (n = 315), had a higher risk of organ failure (50% vs 24%, P < .001) and mortality (20% vs 9%, P < .001). Conclusions Approximately 62% of patients with necrotizing pancreatitis can be treated without an intervention and with low mortality. In patients with infected necrosis, delayed intervention and catheter drainage as first treatment improves outcome.
OBJECTIVE:The aim of this study was to develop an alternative fistula risk score (a-FRS) for postoperative pancreatic fistula (POPF) after pancreatoduodenectomy, without blood loss as a predictor.
...BACKGROUND:Blood loss, one of the predictors of the original-FRS, was not a significant factor during 2 recent external validations.
METHODS:The a-FRS was developed in 2 databasesthe Dutch Pancreatic Cancer Audit (18 centers) and the University Hospital Southampton NHS. Primary outcome was grade B/C POPF according to the 2005 International Study Group on Pancreatic Surgery (ISGPS) definition. The score was externally validated in 2 independent databases (University Hospital of Verona and University Hospital of Pennsylvania), using both 2005 and 2016 ISGPS definitions. The a-FRS was also compared with the original-FRS.
RESULTS:For model design, 1924 patients were included of whom 12% developed POPF. Three predictors were strongly associated with POPFsoft pancreatic texture odds ratio (OR) 2.58, 95% confidence interval (95% CI) 1.80–3.69, small pancreatic duct diameter (per mm increase, OR0.68, 95% CI0.61–0.76), and high body mass index (BMI) (per kg/m increase, OR1.07, 95% CI1.04–1.11). Discrimination was adequate with an area under curve (AUC) of 0.75 (95% CI0.71–0.78) after internal validation, and 0.78 (0.74–0.82) after external validation. The predictive capacity of a-FRS was comparable with the original-FRS, both for the 2005 definition (AUC 0.78 vs 0.75, P = 0.03), and 2016 definition (AUC 0.72 vs 0.70, P = 0.05).
CONCLUSION:The a-FRS predicts POPF after pancreatoduodenectomy based on 3 easily available variables (pancreatic texture, duct diameter, BMI) without blood loss and pathology, and was successfully validated for both the 2005 and 2016 POPF definition. The online calculator is available at www.pancreascalculator.com.
In a 2010 randomized trial (the PANTER trial), a surgical step-up approach for infected necrotizing pancreatitis was found to reduce the composite endpoint of death or major complications compared ...with open necrosectomy; 35% of patients were successfully treated with simple catheter drainage only. There is concern, however, that minimally invasive treatment increases the need for reinterventions for residual peripancreatic necrotic collections and other complications during the long term. We therefore performed a long-term follow-up study.
We reevaluated all the 73 patients (of the 88 patients randomly assigned to groups) who were still alive after the index admission, at a mean 86 months (±11 months) of follow-up. We collected data on all clinical and health care resource utilization endpoints through this follow-up period. The primary endpoint was death or major complications (the same as for the PANTER trial). We also measured exocrine insufficiency, quality of life (using the Short Form-36 and EuroQol 5 dimensions forms), and Izbicki pain scores.
From index admission to long-term follow-up, 19 patients (44%) died or had major complications in the step-up group compared with 33 patients (73%) in the open-necrosectomy group (P = .005). Significantly lower proportions of patients in the step-up group had incisional hernias (23% vs 53%; P = .004), pancreatic exocrine insufficiency (29% vs 56%; P = .03), or endocrine insufficiency (40% vs 64%; P = .05). There were no significant differences between groups in proportions of patients requiring additional drainage procedures (11% vs 13%; P = .99) or pancreatic surgery (11% vs 5%; P = .43), or in recurrent acute pancreatitis, chronic pancreatitis, Izbicki pain scores, or medical costs. Quality of life increased during follow-up without a significant difference between groups.
In an analysis of long-term outcomes of trial participants, we found the step-up approach for necrotizing pancreatitis to be superior to open necrosectomy, without increased risk of reinterventions.
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OBJECTIVE:To study the feasibility and impact of a nationwide training program in minimally invasive distal pancreatectomy (MIDP).
SUMMARY OF BACKGROUND DATA:Superior outcomes of MIDP compared with ...open distal pancreatectomy have been reported. In the Netherlands (2005 to 2013) only 10% of distal pancreatectomies were in a minimally invasive fashion and 85% of surgeons welcomed MIDP training. The feasibility and impact of a nationwide training program is unknown.
METHODS:From 2014 to 2015, 32 pancreatic surgeons from 17 centers participated in a nationwide training program in MIDP, including detailed technique description, video training, and proctoring on-site. Outcomes of MIDP before training (2005–2013) were compared with outcomes after training (2014–2015).
RESULTS:In total, 201 patients were included; 71 underwent MIDP in 9 years before training versus 130 in 22 months after training (7-fold increase, P < 0.001). The conversion rate (38% n = 27 vs 8% n = 11, P < 0.001) and blood loss were lower after training and more pancreatic adenocarcinomas were resected (7 10% vs 28 22%, P = 0.03), with comparable R0-resection rates (4/7 57% vs 19/28 68%, P = 0.67). Clavien-Dindo score ≥III complications (15 21% vs 19 15%, P = 0.24) and pancreatic fistulas (20 28% vs 41 32%, P = 0.62) were not significantly different. Length of hospital stay was shorter after training (9 7–12 vs 7 5–8 days, P < 0.001). Thirty-day mortality was 3% vs 0% (P = 0.12).
CONCLUSION:A nationwide MIDP training program was feasible and followed by a steep increase in the use of MIDP, also in patients with pancreatic cancer, and decreased conversion rates. Future studies should determine whether such a training program is applicable in other settings.
Auditing is an important tool to identify practice variation and ‘best practices’. The Dutch Pancreatic Cancer Audit is mandatory in all 18 Dutch centers for pancreatic surgery.
Performance ...indicators and case-mix factors were identified by a PubMed search for randomized controlled trials (RCT's) and large series in pancreatic surgery. In addition, data dictionaries of two national audits, three institutional databases, and the Dutch national cancer registry were evaluated. Morbidity, mortality, and length of stay were analyzed of all pancreatic resections registered during the first two audit years. Case ascertainment was cross-checked with the Dutch healthcare inspectorate and key-variables validated in all centers.
Sixteen RCT's and three large series were found. Sixteen indicators and 20 case-mix factors were included in the audit. During 2014–2015, 1785 pancreatic resections were registered including 1345 pancreatoduodenectomies. Overall in-hospital mortality was 3.6%. Following pancreatoduodenectomy, mortality was 4.1%, Clavien–Dindo grade ≥ III morbidity was 29.9%, median (IQR) length of stay 12 (9–18) days, and readmission rate 16.0%. In total 97.2% of >40,000 variables validated were consistent with the medical charts.
The Dutch Pancreatic Cancer Audit, with high quality data, reports good outcomes of pancreatic surgery on a national level.
BACKGROUND:Textbook outcome (TO) is a multidimensional measure for quality assurance, reflecting the “ideal” surgical outcome.
METHODS:Post-hoc analysis of patients who underwent ...pancreatoduodenectomy (PD) or distal pancreatectomy (DP) for all indications between 2014 and 2017, queried from the nationwide prospective Dutch Pancreatic Cancer Audit. An international survey was conducted among 24 experts from 10 countries to reach consensus on the requirements for TO in pancreatic surgery. Univariable and multivariable logistic regression was performed to identify TO predictors. Between-hospital variation in TO rates was compared using observed-versus-expected rates.
RESULTS:Based on the survey (92% response rate), TO was defined by the absence of postoperative pancreatic fistula, bile leak, postpancreatectomy hemorrhage (all ISGPS grade B/C), severe complications (Clavien–Dindo ≥III), readmission, and in-hospital mortality. Overall, 3341 patients were included (2633 (79%) PD and 708 (21%) DP) of whom 60.3% achieved TO; 58.3% for PD and 67.4% for DP. On multivariable analysis, ASA class 3 predicted a worse TO rate after PD (ASA 3 OR 0.59 0.44–0.80), whereas a dilated pancreatic duct (>3 mm) and pancreatic ductal adenocarcinoma (PDAC) were associated with a better TO rate (OR 2.22 2.05–3.57 and OR 1.36 1.14–1.63, respectively). For DP, female sex and the absence of neoadjuvant therapy predicted better TO rates (OR 1.38 1.01–1.90 and OR 2.53 1.20–5.31, respectively). When comparing institutions, the observed-versus-expected rate for achieving TO varied from 0.71 to 1.46 per hospital after casemix-adjustment.
CONCLUSIONS:TO is a novel quality measure in pancreatic surgery. TO varies considerably between pancreatic centers, demonstrating the potential benefit of quality assurance programs.
To describe the long-term consequences of necrotising pancreatitis, including complications, the need for interventions and the quality of life.
Long-term follow-up of a prospective multicentre ...cohort of 373 necrotising pancreatitis patients (2005-2008) was performed. Patients were prospectively evaluated and received questionnaires. Readmissions (ie, for recurrent or chronic pancreatitis), interventions, pancreatic insufficiency and quality of life were compared between initial treatment groups: conservative, endoscopic/percutaneous drainage alone and necrosectomy. Associations of patient and disease characteristics during index admission with outcomes during follow-up were assessed.
During a median follow-up of 13.5 years (range 12-15.5 years), 97/373 patients (26%) were readmitted for recurrent pancreatitis. Endoscopic or percutaneous drainage was performed in 47/373 patients (13%), of whom 21/47 patients (45%) were initially treated conservatively. Pancreatic necrosectomy or pancreatic surgery was performed in 31/373 patients (8%), without differences between treatment groups. Endocrine insufficiency (126/373 patients; 34%) and exocrine insufficiency (90/373 patients; 38%), developed less often following conservative treatment (p<0.001 and p=0.016, respectively). Quality of life scores did not differ between groups. Pancreatic gland necrosis >50% during initial admission was associated with percutaneous/endoscopic drainage (OR 4.3 (95% CI 1.5 to 12.2)), pancreatic surgery (OR 3.2 (95% CI 1.1 to 9.5) and development of endocrine insufficiency (OR13.1 (95% CI 5.3 to 32.0) and exocrine insufficiency (OR6.1 (95% CI 2.4 to 15.5) during follow-up.
Acute necrotising pancreatitis carries a substantial disease burden during long-term follow-up in terms of recurrent disease, the necessity for interventions and development of pancreatic insufficiency, even when treated conservatively during the index admission. Extensive (>50%) pancreatic parenchymal necrosis seems to be an important predictor of interventions and complications during follow-up.
To describe outcome after pancreatic surgery in the first 6 years of a mandatory nationwide audit.
Within the Dutch Pancreatic Cancer Group, efforts have been made to improve outcome after pancreatic ...surgery. These include collaborative projects, clinical auditing, and implementation of an algorithm for early recognition and management of postoperative complications. However, nationwide changes in outcome over time have not yet been described.
This nationwide cohort study included consecutive patients after pancreatoduodenectomy (PD) and distal pancreatectomy from the mandatory Dutch Pancreatic Cancer Audit (January 2014-December 2019). Patient, tumor, and treatment characteristics were compared between 3 time periods (2014-2015, 2016-2017, and 2018-2019). Short-term surgical outcome was investigated using multilevel multivariable logistic regression analyses. Primary endpoints were failure to rescue (FTR) and in-hospital mortality.
Overall, 5345 patients were included, of whom 4227 after PD and 1118 after distal pancreatectomy. After PD, FTR improved from 13% to 7.4% odds ratio (OR) 0.64, 95% confidence interval (CI) 0.50-0.80, P <0.001 and in-hospital mortality decreased from 4.1% to 2.4% (OR 0.68, 95% CI 0.54-0.86, P =0.001), despite operating on more patients with age >75 years (18%-22%, P =0.006), American Society of Anesthesiologists score ≥3 (19%-31%, P <0.001) and Charlson comorbidity score ≥2 (24%-34%, P <0.001). The rates of textbook outcome (57%-55%, P =0.283) and major complications remained stable (31%-33%, P =0.207), whereas complication-related intensive care admission decreased (13%-9%, P =0.002). After distal pancreatectomy, improvements in FTR from 8.8% to 5.9% (OR 0.65, 95% CI 0.30-1.37, P =0.253) and in-hospital mortality from 1.6% to 1.3% (OR 0.88, 95% CI 0.45-1.72, P =0.711) were not statistically significant.
During the first 6 years of a nationwide audit, in-hospital mortality and FTR after PD improved despite operating on more high-risk patients. Several collaborative efforts may have contributed to these improvements.
Background
The role of robotic assistance in colorectal cancer surgery has not been established yet. We compared the results of robotic assisted with those of laparoscopic rectal resections done by ...two surgeons experienced in laparoscopic as well as in robotic rectal cancer surgery.
Methods
Two surgeons who were already experienced laparoscopic colorectal surgeons in 2005 started robotic surgery with the daVinci SI system in 2012. All their rectal cancer resections between 2005 and 2015 were retrieved from a prospectively recorded colorectal database of routinely collected patient data. Multi-organ resections were excluded. Patient data, diagnostic data, data on preceding operations and neoadjuvant treatment, perioperative and operative data, logistic data, and short-term outcomes were gathered. Multivariable analyses (multiple linear and logistic regression) were used to assess differences in several outcomes between the two resection methods while adjusting for all potential confounders we could identify. Results are presented as adjusted mean differences for continuous outcome variables or as adjusted odds ratios (OR) for dichotomous outcome variables.
Results
Three hundred and fifty-two patients with rectal cancers were identified: 168 robotic and 184 conventional laparoscopic cases, 178 operated by surgeon A and 174 operated by surgeon B. Adjusted mean operation time was 215 min in the robotic group which was 40 min (95% CI 24–56;
p
< 0.0005) longer than the 175 min in the laparoscopic group. Robotic treatment had significantly lesser numbers of conversions (OR 0.09 (0.03–0.32);
p
< 0.0005) and other complications (SSI and anastomic leakage excluded) (OR 0.32 (0.15–0.69);
p
= 0.004), adjusted for potential confounders.
Conclusions
Our study suggests that robotic surgery in the hands of experienced laparoscopic rectal cancer surgeons improves the conversion rate and complication rate drastically compared to conventional laparoscopic surgery, but operation time is longer.
In the mandatory nationwide Dutch Pancreatic Cancer Audit, rates of major complications and Failure to Rescue (FTR) after pancreatoduodenectomy between low- and high-mortality hospitals are compared, ...and independent predictors for FTR investigated.
Patients undergoing pancreatoduodenectomy in 2014 and 2015 in The Netherlands were included. Hospitals were divided into quartiles based on mortality rates. The rate of major complications (Clavien-Dindo ≥3) and death after a major complication (FTR) were compared between these quartiles. Independent predictors for FTR were identified by multivariable logistic regression analysis.
Out of 1.342 patients, 391 (29%) developed a major complication and in-hospital mortality was 4.2%. FTR occurred in 56 (14.3%) patients. Mortality was 0.9% in the first hospital quartile (4 hospitals, 327 patients) and 8.1% in the fourth quartile (5 hospitals, 310 patients). The rate of major complications increased by 40% (25.7% vs 35.2%) between the first and fourth hospital quartile, whereas the FTR rate increased by 560% (3.6% vs 22.9%). Independent predictors of FTR were male sex (OR = 2.1, 95%CI 1.2–3.9), age >75 years (OR = 4.3, 1.8–10.2), BMI ≥30 (OR = 2.9, 1.3–6.6), histopathological diagnosis of periampullary cancer (OR = 2.0, 1.1–3.7), and hospital volume <30 (OR = 3.9, 1.6–9.6).
Variations in mortality between hospitals after pancreatoduodenectomy were explained mainly by differences in FTR, rather than the incidence of major complications.
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