Unique predictors and economic burden of superficial and deep/organ space surgical site infections following pancreatectomy.

BACKGROUND: Surgical site infections (SSIs) are common following pancreatectomy and associated with significant morbidity and economic burden. We sought to identify distinct predictors for superficial versus deep/organ space SSIs and their effects on surgical outcomes. METHODS: ACS-NSQIP targeted pancreatectomy 2014 and 2015 databases were queried. Univariate and multivariate models were developed for both types of SSI, length of stay (LOS), and readmission. Costs were estimated based on Centers for Medicare & Medicaid Services (CMS) recommendations. RESULTS: Of 8093 patients, there were 422 (5.2%) superficial and 1005 (12.4%) deep/organ space SSIs. On multivariate analyses, preoperative biliary stenting was predictive only for superficial SSI (OR: 2.21), while BMI of 25-29.9 (OR: 1.25) and BMI ≥30 kg/m2 (OR: 1.53), pancreatic duct size <3 mm (OR: 1.30), and intermediate (OR: 1.67) versus hard gland texture were predictors of deep/organ-space SSI. Superficial and deep/organ space SSIs were independent predictors of prolonged LOS (OR: 1.74 vs 1.80) and readmission (OR: 2.59 vs 6.57). Additional readmission costs per patient secondary to superficial SSI and deep/organ space SSI were $7661.37 and $18,409.42, respectively. CONCLUSION: Deep/organ space SSI contributes more profoundly to prolonged hospital stay, readmission, and additional costs, suggesting that strategies should focus on preferential prevention of deep/organ space infections.

Pancreas fistula risk prediction: implications for hospital costs and payments.

BACKGROUND: As payment models evolve, disease-specific risk stratification may impact patient selection and financial outcomes. This study sought to determine whether a validated clinical risk score for post-operative pancreatic fistula (POPF) could predict hospital costs, payments, and profit margins. METHODS: A multi-institutional cohort of 1193 patients undergoing pancreaticoduodenectomy (PD) were matched to an independent hospital where cost, in US$, and payment data existed. An analytic model detailed POPF risk and post-operative sequelae, and their relationship with hospital cost and payment. RESULTS: Per-patient hospital cost for negligible-risk patients was $37,855. Low-, moderate-, and high- risk patients had incrementally higher hospital costs of $38,125 ($270; 0.7% above negligible-risk), $41,128 ($3273; +8.6%), and $41,983 ($3858; +10.9%), respectively. Similarly, hospital payment for negligible-risk patients was $42,685/patient, with incrementally higher payments for low-risk ($43,265; +1.4%), moderate-risk ($45,439; +6.5%) and high-risk ($46,564; +9.1%) patients. The lowest 30-day readmission rates - with highest net profit - were found for negligible/low-risk patients (10.5%/11.1%), respectively, compared with readmission rates of moderate/high-risk patients (15%/15.7%). CONCLUSION: Financial outcomes following PD can be predicted using the FRS. Such prediction may help hospitals and payers plan for resource allocation and payment matched to patient risk, while providing a benchmark for quality improvement initiatives.

Comparing the burden of pancreatic fistulas after pancreatoduodenectomy and distal pancreatectomy.

BACKGROUND: Differences in the behavior of postoperative pancreatic fistulas (POPF) have been described after various pancreatic resections. Here, we compare POPFs after pancreatoduodenectomy (PD) and distal pancreatectomy (DP) using the average complication burden (ACB), a quantitative measure of complication burden. METHODS: From 2001 to 2014, 837 DPs and 1,533 PDs were performed by 14 surgeons at 4 institutions. POPFs were categorized by International Study Group on Pancreatic Fistula standards as biochemical (grade A) or clinically relevant (CR-POPF; grades B and C). ACB values were derived from fistula severity scores based on the Modified Accordion Severity Grading. The ACB of POPFs was compared between PD and DP. RESULTS: POPFs were more common after DP compared with PD (34.5 vs 27.2%; P < .001); however, the incidence of any complication was greater after PD (64.9 vs 53.2%; P < .001). When POPFs occurred, they were more likely to be the highest-graded complication after DP compared with PD (65.1 vs 51.6%; P < .001). ACB significantly varied between PDs and DPs for grade C POPFs (0.804 vs 0.611; P < .001). POPFs accounted for 31.2% of the overall complication burden after DP compared with 17.5% of the burden after PD. ACB differed significantly across both institutions and surgeons in terms of POPFs, nonfistulous complications, and overall complications (all P < .05). CONCLUSION: Although POPFs occur less frequently after PD, they are associated with a greater complication burden compared with DP. ACB varies significantly between health care providers, suggesting the need for risk-adjusted comparisons of complication severity. Using ACB to evaluate a distinct morbidity has the potential to aid in assessing the impact of procedure-specific complications.

Surgical management of chronic pancreatitis: current utilization in the United States.

BACKGROUND: Surgical intervention is uncommon in chronic pancreatitis. Literature largely describes single institution or international experiences. This study describes US-based chronic pancreatitis surgical management. METHODS: Retrospective analysis of chronic pancreatitis patients in the Healthcare Cost and Utilization Project Florida State Inpatient Database 2007-2011. Patients with malignancy or congenital abnormalities were excluded. Univariate analysis using the chi-square test. The number of readmissions, inpatient length of stay and cost using Wilcoxon's signed-rank test. Multivariate analysis of surgery by logistic regression. RESULTS: Twenty-one thousand four hundred and forty-five patients with chronic pancreatitis. 10.8% (2 307) underwent surgery including 1652 cholecystectomies, 564 drainage procedures and 498 pancreatectomies. Procedures decreased from 12.1% to 8.3% over time (P < 0.001), but intervention within 3 months increased (7.2% to 8.4%; P = 0.017). 15.3% (3 278) had pancreatic cysts/pseudocysts and 43.4% (9 312) had diabetes. The median numbers of admissions were 2 [interquartile range (IQR) 1,5] and 3 (IQR 2,7) among non-surgical and surgical patients, respectively (P < 0.001). Predictors of surgery were fewer co-morbidities, private insurance, and either diabetes mellitus or pancreatic cyst/pseudocyst. CONCLUSION: Chronic pancreatitis leads to numerous inpatient readmissions, but surgical intervention only occurs in a minority of cases. Complicated patients are more likely to undergo surgery. The complexities of chronic pancreatitis management warrant early multidisciplinary evaluation and ongoing consideration of surgical and non-surgical options.

A nationwide assessment of outcomes after bile duct reconstruction.

BACKGROUND: Bile duct reconstruction (BDR) is used to manage benign and malignant neoplasms, congenital anomalies, bile duct injuries and other non-malignant diseases. BDR outcomes overall, by year, and by indication were compared. METHODS: Retrospective analysis of Nationwide Inpatient Sample discharges (2004-2011) including ICD-9 codes for BDR. All statistical testing was performed using survey weighting. Univariate analysis of admission characteristics by chi square testing. Multivariate modelling for inpatient complications and inpatient death by logistic regression. RESULTS: Identified 67 160 weighted patient admissions: 2.5% congenital anomaly, 37.4% malignant neoplasm, 2.3% benign neoplasm, 9.9% biliary injury, 47.9% other non-malignant disease. Most BDRs were performed in teaching hospitals (69.6%) but only 25% at centres with a BDR volume more than 35/year. 32.3% involved ≥ 1 complication, and 84.7% were discharges home. There was a 4.2% inpatient death rate. The complication rate increased but the inpatient death rate decreased over time. The rates of acute renal failure increased. Significant multivariate predictors of inpatient death include indication of biliary injury or malignancy, and predictors of any complication include public insurance and non-elective admission. CONCLUSION: This is the first national description of BDRs using a large database. In this diverse sampling, both procedure indication and patient characteristics influence morbidity and mortality.

Patient selection and the volume effect in pancreatic surgery: unequal benefits?

BACKGROUND: The volume effect in pancreatic surgery is well established. Regionalization to high-volume centres has been proposed. The effect of this proposal on practice patterns is unknown. METHODS: Retrospective review of pancreatectomy patients in the Nationwide Inpatient Sample 2004-2011. Inpatient mortality and complication rates were calculated. Patients were stratified by annual centre pancreatic resection volume (low <5, medium 5-18, high >18). Multivariable regression model evaluated predictors of resection at a high-volume centre. RESULTS: In total, 129,609 patients underwent a pancreatectomy. The crude inpatient mortality rate was 4.3%. 36.0% experienced complications. 66.5% underwent a resection at high-volume centres. In 2004, low-, medium- and high-volume centres resected 16.3%, 24.5% and 59.2% of patients, compared with 7.6%, 19.3% and 73.1% in 2011. High-volume centres had lower mortality (P < 0.001), fewer complications (P < 0.001) and a shorter median length of stay (P < 0.001). Patients at non-high-volume centres had more comorbidities (P = 0.001), lower rates of private insurance (P < 0.001) and more non-elective admissions (P < 0.001). DISCUSSION: In spite of a shift to high-volume hospitals, a substantial cohort still receives a resection outside of these centres. Patients receiving non-high-volume care demonstrate less favourable comorbidities, insurance and urgency of operation. The implications are twofold: already disadvantaged patients may not benefit from the high-volume effect; and patients predisposed to do well may contribute to observed superior outcomes at high-volume centres.

Is routine intraoperative cholangiogram necessary in the twenty-first century? A national view.

INTRODUCTION: Intraoperative cholangiogram (IOC) can define biliary ductal anatomy. Routine IOC has been proposed previously. However, current surgeon IOC utilization practice patterns and outcomes are unclear. METHODS: Nationwide Inpatient Sample 2004-2009 was queried for patients with acute biliary disease undergoing cholecystectomy (CCY). Analyses only included surgeons performing ≥10 CCY/year. We dichotomized surgeons into a routine IOC group vs. selective. Outcomes included bile duct injury, complications, mortality, length of stay, and cost. RESULTS: Of the nonweighted patients, 111,815 underwent CCY. A total of 4,740 actual surgeon yearly volumes were examined. On average, each surgeon performed 23.6 CCYs and 7.9 IOCs annually, using IOC in 33 % of cases. The routine IOC group used IOC for 96 % of cases, whereas selective IOC group used IOC ∼25 % of the time. Routine IOC surgeons had no difference in mortality (0.4 %) or rate of bile duct injury (0.25 vs. 0.26 %), but higher overall complications (7.3 vs. 6.8 %, p = 0.04). Patients of routine IOC surgeons received more additional procedures and incurred higher costs. CONCLUSION: Routine IOC does not decrease the rate of bile duct injury, but is associated with significant added cost. Surgeons' routine use of IOC is correlated with increased rates of postsurgical procedures, and is associated with increased overall complications. These data suggest routine IOC may not improve outcomes.

Pancreatic surgery: a multidisciplinary assessment of the value of intraoperative US.

PURPOSE: To assess the value of intraoperative ultrasonography (US) for different types of pancreatic surgery. MATERIALS AND METHODS: An institutional review board-approved, HIPAA-compliant retrospective review with waiver of informed consent was performed to evaluate all cases of pancreatic surgery with intraoperative US or laparoscopic US that occurred at a single institution during a 10-year period. Surgical notes, radiologic images, and clinical data for each surgical procedure and subsequent clinical course were reviewed by pancreatic surgeons and radiologists. Presumptive diagnosis, type of surgical procedure performed, and final pathologic data were recorded. A relative value score was established by consensus and assigned to each case with a grade of 0-3, which indicated the value of the intraoperative or laparoscopic US. The type of operation and pathologic data were compared in each of the value score groups. Categoric variables were compared by using either χ(2) or Fisher exact test. RESULTS: One hundred ninety-three intraoperative or laparoscopic US procedures were performed in 189 patients. Of the patients, there were 102 men and 87 women. The mean age was 57.8 years (range, 18-86 years). Intraoperative or laparoscopic US value scores were as follows: value score 0, 3.6%; value score 1, 11.9%; value score 2, 31.1%; and value score 3, 53.4%. The most common contribution that resulted in a high score (value score 3) was facilitation of technical performance of the surgery (n = 60). High value score was significantly associated with performance of pancreatitis-related surgery (P < .001). The surgical indication that most commonly resulted in a low value score of 0 or 1 was staging of pancreatic cancers. All cases that received a score of 0 occurred in the laparoscopic adenocarcinoma surgical setting (staging or pancreatic biopsy). CONCLUSION: Intraoperative or laparoscopic US can be a valuable procedure in multiple types of surgical procedures that involve the pancreas and shows clear patterns of value in the different types of surgery.

The burden of infection for elective pancreatic resections.

BACKGROUND: Infection control is potentially a critical quality indicator but remains incompletely understood, especially in high-acuity gastrointestinal surgery. Our objective was to evaluate the incidence and impact of infections after elective pancreatectomy at the practice level. METHODS: All pancreatectomies performed by three pancreatic surgical specialists over an 8-year period (2001-2009) followed standardized perioperative care, including timely antibiotic administration. Infections were defined according to National Surgery Quality Improvement Program criteria, while complication severity was based on Clavien grade. Clinical and economic outcomes were evaluated and predictors of infection identified by regression analysis. RESULTS: Of 550 major pancreatic resections, 288 (53%) had some complication, of which 167 (31%) were infectious. Rates of infection differed by type of resection (proximal pancreatectomy > others; P = .029) but not by presence of malignancy. Major infections (Clavien 3-5; n = 62), occurred in 11% of cases. Infection was not the primary cause of death in any patient. Infection was associated with increases in hospital stay, operative times, transfusions, blood loss, intensive care unit use, and readmission (34% vs 12%). Types of infection were as follows: wound infection (14%), infected pancreatic fistula (9%), urinary tract infection (7%), pneumonia (6%), and sepsis (2%). The use of total parenteral nutrition (odds ratio [OR], 7.3), coronary artery disease (OR, 2.1), and perioperative hypotension (OR, 1.6) predicted any infection. Total costs for cases with infection increased grade-for-grade across the Clavien scale, with infection accounting for 38% of the overall cost differential. CONCLUSION: Infectious complications occurred frequently, compromising numerous outcomes and increasing costs markedly. These data provide a foundation for understanding the baseline consequences of infection in high-acuity gastrointestinal surgery and offer opportunities for process evaluation and initiatives in infection control at the practice level.

Quality assessment in pancreatic surgery: what might tomorrow require?

INTRODUCTION: The Institute of Medicine (IOM) defines healthcare quality across six domains: safety, timeliness, effectiveness, patient centeredness, efficiency, and equitability. We asked experts in pancreatic surgery (PS) whether improved quality metrics are needed, and how they could align to contemporary IOM healthcare quality domains. METHODS: We created and distributed a web-based survey to pancreatic surgeons. Respondents ranked 62 proposed PS quality metrics on level of importance (LoI) and aligned each metric to one or more IOM quality domains (multi-domain alignment (MDA)). LoI and MDA scores for a given quality metric were averaged together to render a total quality score (TQS) normalized to a 100-point scale. RESULTS: One hundred six surgeons (21 %) completed the survey. Ninety percent of respondents indicated a definite or probable need for improved quality metrics in PS. Metrics related to mortality, to rates and severity of complications, and to access to multidisciplinary services had the highest TQS. Metrics related to patient satisfaction, costs, and patient demographics had the lowest TQS. The least represented IOM domains were equitability, efficiency, and patient-centeredness. CONCLUSIONS: Experts in pancreatic surgery have significant consensus on 12 proposed metrics of quality that they view as both highly important and aligned with more than one IOM healthcare quality domain.

A prospectively validated clinical risk score accurately predicts pancreatic fistula after pancreatoduodenectomy.

BACKGROUND: Clinically relevant postoperative pancreatic fistulas (CR-POPF) are serious inherent risks of pancreatic resection. Preoperative CR-POPF risk assessment is currently inadequate and rarely disqualifies patients who need resection. The best evaluation of risk occurs intraoperatively, and should guide fistula prevention and response measures thereafter. We sought to develop a risk prediction tool for CR-POPF that features intraoperative assessment and reveals associated clinical and economic significance. STUDY DESIGN: Based on International Study Group of Pancreatic Fistula classification, recognized risk factors for CR-POPF (small duct, soft pancreas, high-risk pathology, excessive blood loss) were evaluated during pancreaticoduodenectomy. An optimal risk score range model, selected from 3 different constructs, was first derived (n = 233) and then validated prospectively (n = 212). Clinical and economic outcomes were evaluated across 4 ranges of scores (negligible risk, 0 points; low risk, 1 to 2; intermediate risk, 3 to 6; high risk, 7 to 10). RESULTS: Clinically relevant postoperative pancreatic fistulas occurred in 13% of patients. The incidence was greatest with excessive blood loss. Duct size <5 mm was associated with increased fistula rates that rose with even smaller ducts. These factors, together with soft pancreatic parenchyma and certain disease pathologies, afforded a highly predictive 10-point Fistula Risk Score. Risk scores strongly correlated with fistula development (p < 0.001). Notably, patients with scores of 0 points never developed a CR-POPF, while fistulas occurred in all patients with scores of 9 or 10. Other clinical and economic outcomes segregated by risk profile across the 4 risk strata. CONCLUSIONS: A simple 10-point Fistula Risk Score derived during pancreaticoduodenectomy accurately predicts subsequent CR-POPF. It can be readily learned and broadly deployed. This prediction tool can help surgeons anticipate, identify, and manage this ominous complication from the outset.

Readmission after major pancreatic resection: a necessary evil?

BACKGROUND: Hospital readmission is under increased scrutiny as a quality metric for surgical performance, yet its relevance after elective, high-acuity operations is poorly understood. We sought to define the clinical nature and economic impact of readmission after major pancreatic resection. STUDY DESIGN: From 2001 to 2009, 578 pancreatic resections followed standardized perioperative care. Clinical and economic outcomes were evaluated and predictors of readmission were identified by regression analysis. RESULTS: One hundred and eleven (19%) patients required readmission within 30 days (median 8 days post discharge), with only 12 more readmitted between 31 and 90 days. Twenty-three (21%) patients were readmitted multiple times. Reasons for readmission were procedure-specific complications (48%), general postoperative complications/infections (18.0%), failure to thrive (12%), or medical problems (9%). An additional 14% were readmitted solely for diagnostic evaluation of symptoms without cause. Neither preoperative demographics/acuity nor intraoperative factors influenced readmission. Instead, readmission was predicted by any (odds ratio = 2.24) or major (odds ratio = 2.19) complications, and clinically relevant (odds ratio = 5.05) or latent (odds ratio = 4.04) pancreatic fistula. Patient survival was negatively, but not significantly, associated with readmissions. Overall hospital stay and costs were markedly affected by readmission, as readmitted patients cost an average of $16,000 more. CONCLUSIONS: In this practice-based analysis, readmissions after pancreatic resection were frequent, early, costly, and largely related to procedure-specific complications. As initial hospital stay continues to decline in high-acuity surgery, readmissions might be required for optimal management of complications, which often manifest later in the recovery course. Clinical pathway deviations predict potential readmissions, and might prompt adjustments in management and disposition of patients at risk for returning to the hospital.

Malpractice carrier underwrites Fundamentals of Laparoscopic Surgery training and testing: a benchmark for patient safety.

BACKGROUND: Fundamentals of Laparoscopic Surgery (FLS) is a validated program developed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) to educate and assess competency in minimally invasive surgery (MIS). This study reports the first malpractice carrier-sponsored FLS course for surgeons in practice underwritten by the Controlled Risk Insurance Company of Harvard's Risk Management Foundation (CRICO/RMF). The study investigated the participating surgeons' pattern of MIS skills acquisition, subjective laparoscopic comfort level, operative activity, and perception of the FLS role in surgical education, credentialing, and patient safety. METHODS: A 1-day postgraduate continuous medical education (CME) course consisted of didactic presentations of the leading MIS faculty, proctored FLS hands-on training, psychomotor testing, and cognitive computer-based examination. Voluntary anonymous pre- and postcourse surveys were distributed to the participants at registration and at completion of both the didactic teaching and the skills modules of the program. RESULTS: The course was attended by 37 practicing surgeons in the Harvard system, and 86% of the survey forms were returned. The major driving forces for attending the course were directive from the chief/chairman (50%), improvement in MIS didactic knowledge (56%), and the belief that FLS would become a standard such as advanced trauma life support (ATLS), advanced cardiac life support (ACLS), or the like (53%). Surgeons reported that the FLS exam content was appropriate (Likert 4.41 +/- 0.91) and that mastery of the course material would improve safety (Likert 4.13 +/- 0.79) and technical knowledge of MIS (Likert 4.03 +/- 1.00). CONCLUSIONS: This unique cooperative effort between a liability carrier, a professional surgical society, and proactive surgeons should be considered a model for advancing competency and patient safety. The survey results indicate a positive view of FLS in surgical training, safety, and MIS education.

Establishing standards of quality for elderly patients undergoing pancreatic resection.

OBJECTIVE: To evaluate pancreatic surgery as a model for high-acuity surgery in elderly patients for immediate and long-term outcomes, predictors of adverse outcomes, and hospital costs. DESIGN: Retrospective case series. SETTING: University tertiary care referral center. PATIENTS: Four hundred twelve consecutive patients who underwent pancreatic resection from October 1, 2001, through March 31, 2008, for benign and malignant periampullary conditions. MAIN OUTCOME MEASURES: Clinical outcomes were compared for elderly (> or = 75 years) and nonelderly patient cohorts. Quality assessment analyses were performed to show the differential impact of complications and resource utilization between the groups. RESULTS: The elderly cohort constituted one-fifth of all patients. Benchmark standards of quality were achieved in this group, including low operative mortality (1%). Despite higher patient acuity, clinical outcomes were comparable to those of nonelderly patients at a marginal cost increase (median, $2202 per case). Cost modeling analysis showed further that minor and moderate complications were more frequent but no more debilitating for elderly patients. Major complications, however, were far more threatening to older patients. In these cases, duration of hospital stay doubled, and invasive interventions were more commonly deployed. CONCLUSIONS: Quality standards for pancreatic resection in the elderly can--and should--mirror those for younger patients. Age-related care, including geriatric consultation, supplemental enteral nutrition, and early rehabilitation placement planning, can be designed to mitigate the impact of complications in the elderly and guarantee quality.

Optimal surgical performance attenuates physiologic risk in high-acuity operations.

BACKGROUND: The interplay between baseline physiology, operative performance, and postoperative recovery is poorly defined. We describe the beneficial effect of a successful operation on outcomes across the full spectrum of physiologic risk for an elective high-acuity procedure. STUDY DESIGN: Four hundred twelve consecutive pancreatic resections, performed between 2001 and 2008, were analyzed according to the Physiologic and Operative Severity Score for the Enumeration of Mortality and Morbidity. Baseline physiology was classified according to the Physiologic Severity Score: minor (< or = 16); intermediate (17 to 23); vulnerable (> or = 24). Surgical performance was assigned by the Operative Severity Score: class I (< or = 14); class II (15 to 17); class III (> or = 18). Physiologic and operative predictions were independently correlated with actual clinical and economic outcomes and then merged to measure the influence of surgical performance beyond baseline physiology. RESULTS: As baseline physiology declines, patients suffer more complications and require more therapeutic and invasive interventions. Within each physiologic risk grade, class I operations (optimal surgical performances) were associated with lower rates of morbidity, shorter hospital stays, and improved cost efficiency. Deeper analysis reveals that intraoperative blood loss is the most variable and influential factor affecting physiologic risk. Each additional unit (375 mL) of blood loss increases the odds of morbidity by 45%, prolongs hospital stay by 1 day, and costs an additional $4,000 per patient. CONCLUSIONS: Predictive risk assessment accurately demonstrates that escalating physiologic risk worsens postoperative morbidity, prolongs hospital duration, and increases costs after such high-acuity operations. These effects are attenuated by improved operative performance.

Risk prediction for development of pancreatic fistula using the ISGPF classification scheme.

BACKGROUND: The International Study Group on Pancreatic Fistula (ISGPF) classification scheme has become a useful system for characterizing the clinical impact of pancreatic fistula. We sought to identify predictive factors that predispose patients to fistula, specifically those with clinical relevance (grades B/C), and to describe the clinical and economic significance of risk stratification within this framework. METHODS: Overall, 233 consecutive pancreatoduodenectomies were performed between October 2001 and March 2007 in our institution. Pancreatic fistula is defined according to the ISGPF classification scheme. Logistic regression analysis was performed to identify risk factors for pancreatic fistula development. These features were then analyzed to determine whether additive risk severity equates to worsening clinical and economic impact. RESULTS: Fistulas of any extent occurred in 60 patients, but only 31 (14%) were clinically relevant. There are no identifiable risk factors for grade A biochemical fistulas. Multivariate analysis shows that small pancreatic duct size (<3 mm); soft gland texture; ampullary, duodenal, cystic, or islet cell pathology; and increased intraoperative blood loss (>1,000 ml) are associated with clinically relevant fistulae. An additive effect is further illustrated, in which clinical and economic outcomes progressively worsen as risk profile increases. Each additional risk factor increases the odds of developing a clinically relevant fistula by 52%. CONCLUSIONS: For pancreatoduodenectomy, small duct size; soft gland texture; ampullary, duodenal, cystic, or islet cell pathology; and increased intraoperative blood loss are convincing risk factors for the development clinically relevant fistulae as judged by ISGPF classification. As risk profile accrues, patients suffer more complications, encounter longer hospital stays, and incur greater hospital costs. These outcomes can be predicted in the operating room through accurate delineation of high-risk glands.

POSSUM accurately predicts morbidity for pancreatic resection.

BACKGROUND: The Physiologic and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) is a predictive scoring system for postoperative morbidity. While numerous studies validate its application to major abdominal surgery, few exclusively consider pancreatic resections, whose unique complications are costly and problematic. We examined whether POSSUM could accurately reflect clinical and economic outcomes in pancreatic resection. METHODS: 326 consecutive pancreatic resections (227 pancreaticoduodenectomies, 87 distal, 7 central, and 5 total pancreatectomies) were performed between October 2001 and January 2007. POSSUM score was prospectively calculated for each case, and patients were stratified to quintiles of morbidity risk: < or = 20%, 20-40%, 40-60%, 60-80%, > or = 80%. Actual clinical and economic outcomes were compared across the groups. Predictive risk assessment was further evaluated independently within each resection type. Logistic regression analysis was performed to identify specific POSSUM parameters predictive of postoperative morbidity. RESULTS: Observed and Expected morbidity rates were equivalent (53.1% vs 55.5%) with an overall O/E ratio of 0.96. Although no patients presented with POSSUM scores below 20%, a relatively equal distribution was assigned to the remaining risk cohorts. Clinical and economic outcomes progressively worsened with escalations in POSSUM scores. Increasing morbidity risk was associated with significantly longer hospital stays, higher rates of complications, and more blood transfusions, ICU management, and discharge to rehabilitation facilities. This had considerable economic impact, as mean hospital costs rose from $19,951 in the 20-40% risk cohort, to $31,281 in the > or = 80% group. Breakdown by operation type demonstrates that POSSUM definitively predicts morbidity following both proximal and distal resection, but more accurately forecasts the need for ICU management and rehabilitation placement when pancreatoduodenectomy is performed. Multivariate analysis revealed that one-half of POSSUM parameters were significant contributors for postoperative morbidity, with age, preoperative hemoglobin concentration, and intraoperative blood loss demonstrating the strongest correlations. CONCLUSION: POSSUM is a valuable perioperative scoring system for evaluating variance in pancreatic surgical methods and outcomes, and can be employed to guide management decisions that impact postoperative recovery.

Selective administration of prophylactic octreotide during pancreaticoduodenectomy: a clinical and cost-benefit analysis in low- and high-risk glands.

BACKGROUND: The efficacy of prophylactic octreotide after pancreaticoduodenectomy has been rigorously scrutinized, yet few studies have specifically illustrated its impact in patients at high risk for pancreatic fistula. Applying a previously validated clinical classification scheme (International Study Group on Pancreatic Fistula) for postoperative pancreatic fistula severity, we examined whether prophylactic octreotide could effectuate a clinical or fiscal benefit, or both, after pancreatic resection. STUDY DESIGN: There were 227 consecutive patients who underwent pancreaticoduodenectomy from October 2001 to January 2007. At the surgeon's discretion, prophylactic octreotide was administered intraoperatively and continued postoperatively. Clinically relevant fistulas, requiring therapeutic interventions or resulting in severe clinical sequelae, were identified, as were other complications. Through multivariate analysis, risk factors for fistula were defined as soft gland texture; small duct size; ampullary, duodenal, cystic, or islet cell pathology; and increased blood loss. Beyond a traditional review of clinical outcomes, a novel economic cost-benefit analysis of octreotide prophylaxis was performed, with concentration of impact on high-risk glands (one or more risk factors). RESULTS: Overall, 55% of patients had at least one risk factor. Clinically relevant fistulas were present in 14.9% of all patients. High-risk glands resulted in significantly worse clinical and economic outcomes compared with low-risk glands (no risk factors present). Prophylactic octreotide in low-risk glands was neither clinically effective nor cost efficient after pancreaticoduodenectomy, contributing to $781 in overspending per patient--approximately equivalent to a 7-day postoperative course of octreotide. But in patients with high-risk glands, octreotide prophylaxis was associated with a decreased incidence (20% versus 35%) and morbidity of clinically relevant fistulas. These improved clinical outcomes were associated with reduced resource use, translating to considerable cost savings ($11,849) per high-risk patient. CONCLUSIONS: Octreotide prophylaxis is an effective approach to mitigate the negative impact of pancreatic fistulas, but to obtain maximal clinical value and cost benefit, octreotide should be administered exclusively to patients with high-risk glands.

Quality assessment in high-acuity surgery: volume and mortality are not enough.

HYPOTHESIS: A new quality assessment model for high-acuity surgery links process improvements with hospital costs and patient-centered outcomes and accurately reflects the clinical and economic impact of variance in patient acuity at the level of the practice and health care professional. DESIGN: Retrospective case series and cost analysis. SETTING: University tertiary care referral center. PATIENTS: A total of 296 patients undergoing elective pancreatic resection in 5 years. MAIN OUTCOME MEASURES: Expected preoperative morbidity (evaluated using POSSUM [Physiologic and Operative Severity Score for the Enumeration of Mortality and Morbidity]) was compared with observed morbidity (according to the Clavien complication scheme) and was correlated with total hospital costs per patient. RESULTS: As volume increased annually, patient acuity (expected morbidity) rose and complications declined. Overall, observed and expected morbidity rates were equal (54.1% vs 55.1%), for an observed-expected ratio of 0.98. Process improvement measures contributed to a steady decrease in the observed-expected morbidity ratio from 1.34 to 0.81 during the 5-year period. This decrease was strongly associated with significant cost savings as total costs per patient declined annually (from $31 541 to $18 829). This performance assessment model predicts that a 0.10 decrease in the observed-expected morbidity ratio equates to a $2549 cost savings per patient in our practice. CONCLUSIONS: Despite increasing patient acuity, better clinical and economic outcomes were achieved across time. Approaches that mitigate the impact of preoperative risk can effectively deliver quality improvement, as illustrated by a reduced observed-expected morbidity ratio. This approach is valuable in analyzing performance and process improvements and can be used to assess intrapractice and interpractice variations in high-acuity surgery.