Taking Theory to Practice: Quality Improvement for Pancreaticoduodenectomy and Development and Integration of the Fistula Risk Score.

Published on Oct 1, 2018in Journal of The American College of Surgeons6.113
· DOI :10.1016/J.JAMCOLLSURG.2018.06.009
Brett L. Ecker19
Estimated H-index: 19
(UPenn: University of Pennsylvania),
Matthew T. McMillan25
Estimated H-index: 25
(UPenn: University of Pennsylvania)
+ 1 AuthorsCharles M. Vollmer67
Estimated H-index: 67
(UPenn: University of Pennsylvania)
Sources
Abstract
Background Improvements in surgical outcomes are predicated on recognizing effective practices with subsequent adaptation. It is unknown whether risk assessment for pancreatic fistula (clinically relevant postoperative pancreatic fistula [CR-POPF]) after pancreaticoduodenectomy (PD) translates to improved patient outcomes at the practice level. Study design A prospectively collected, single-surgeon career experience (2003 to 2018) of 455 consecutive pancreatectomies (303 PDs and 152 distal pancreatectomies) was examined. Analysis occurred during 4 eras of practice: learning curve for PD (n = 50); development of the Fistula Risk Score (n = 48); reactive, data-driven adjustments of anastomotic stent use (n = 94); and omission of prophylactic octreotide with adoption of selective drainage (n = 111). Observed to expected ratios of CR-POPF were calculated using a multi-institutional derivation set (5,379 PDs). Results After adjustment for increasing fistula risk across the 4 eras (p = 0.016), the risk-adjusted CR-POPF rate declined significantly (observed to expected ratio 1.42→1.28→1.01→0.30; p Conclusions Patient outcomes for PD can be optimized by risk-adjusted evaluation and deliberate modification of practice.
References38
Newest
#1Brett L. Ecker (UPenn: University of Pennsylvania)H-Index: 19
#2Matthew T. McMillan (UPenn: University of Pennsylvania)H-Index: 25
Last. Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 67
view all 35 authors...
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Last. Marc G. BesselinkH-Index: 88
view all 42 authors...
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 databases: the Dutch Pancreatic Cancer Audit (18 centers) and the University Hospital Southampton NHS. Primary outcome was grade B...
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#1Matthew T. McMillan (UPenn: University of Pennsylvania)H-Index: 25
#2Giuseppe MalleoH-Index: 46
Last. Charles M. VollmerH-Index: 67
view all 13 authors...
Objective:This multicenter study sought to prospectively evaluate a drain management protocol for pancreatoduodenectomy (PD).Background:Recent evidence suggests value for both selective drain placement and early drain removal for PD. Both strategies have been associated with reduced rates of clinica
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#1Claudio BassiH-Index: 111
Last. M.W. Büchler (Heidelberg University)H-Index: 79
view all 33 authors...
Background In 2005, the International Study Group of Pancreatic Fistula developed a definition and grading of postoperative pancreatic fistula that has been accepted universally. Eleven years later, because postoperative pancreatic fistula remains one of the most relevant and harmful complications of pancreatic operation, the International Study Group of Pancreatic Fistula classification has become the gold standard in defining postoperative pancreatic fistula in clinical practice. The aim of th...
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#1Matthew T. McMillan (UPenn: University of Pennsylvania)H-Index: 25
#2Brett L. Ecker (UPenn: University of Pennsylvania)H-Index: 19
Last. Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 67
view all 12 authors...
Background Evidence suggests externalized trans-anastomotic stents may be beneficial as a fistula mitigation strategy for pancreatoduodenectomy (PD); however, previous studies have not been rigorously risk-adjusted.
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#1Matthew T. McMillanH-Index: 25
#2Sameer Soi (Mayo Clinic)H-Index: 6
Last. Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 67
view all 27 authors...
Objective:To evaluate surgical performance in pancreatoduodenectomy using clinically relevant postoperative pancreatic fistula (CR-POPF) occurrence as a quality indicator.Background:Accurate assessment of surgeon and institutional performance requires (1) standardized definitions for the outcome of
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#1Jamie E. Anderson (UC Davis: University of California, Davis)H-Index: 13
#2Zhongmin Li (UC Davis: University of California, Davis)H-Index: 20
Last. David C. Chang (Harvard University)H-Index: 25
view all 5 authors...
Background Public reporting of surgical outcomes must adjust for patient risk. However, whether patient sociodemographic status (SDS) should be included is debatable. Our objective was to empirically compare risk-adjustment models and hospital ratings with or without SDS factors for patients undergoing coronary artery bypass grafting. Study Design This is a retrospective analysis of the California Coronary Artery Bypass Grafting Outcomes Reporting Program, 2011–2012. Outcomes included 30-day or ...
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#1Matthew T. McMillan (UPenn: University of Pennsylvania)H-Index: 25
#2John D. Christein (UA: University of Alabama)H-Index: 36
Last. Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 67
view all 12 authors...
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...
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#1Laurent G. Glance (USU: Uniformed Services University of the Health Sciences)H-Index: 44
Last. Andrew W. DickH-Index: 56
view all 6 authors...
To assess whether differences in readmission rates between safety-net hospitals (SNH) and non-SNHs are due to differences in hospital quality, and to compare the results of hospital profiling with and without SES adjustment.In response to concerns that quality measures unfairly penalizes SNH, NQF recently recommended that performance measures adjust for socioeconomic status (SES) when SES is a risk factor for poor patient outcomes.Multivariate regression was used to examine the association betwe...
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#1Matthew T. McMillan (UPenn: University of Pennsylvania)H-Index: 25
#2Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 67
Last. Stephen W. Behrman (UTHSC: University of Tennessee Health Science Center)H-Index: 31
view all 29 authors...
Introduction International Study Group of Pancreatic Fistula (ISGPF) grade C postoperative pancreatic fistulas (POPF) are the greatest contributor to major morbidity and mortality following pancreatoduodenectomy (PD); however, their infrequent occurrence has hindered deeper analysis. This study sought to develop a predictive algorithm, which could facilitate effective management of this challenging complication.
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Cited By12
Newest
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#1Tianyu Tang (Soochow University (Taiwan))H-Index: 2
#2Yuwei TanH-Index: 2
Last. Xuemin Chen (Soochow University (Taiwan))H-Index: 12
view all 8 authors...
Background: Overweight and obesity are increasing year by year all over the world, and there is a correlation between overweight and obesity and the risk of pancreatic cancer. However, the relation...
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#1Tommaso GiulianiH-Index: 4
Last. Claudio BassiH-Index: 3
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#1Fabio Casciani (UPenn: University of Pennsylvania)H-Index: 3
#2Maxwell T. Trudeau (UPenn: University of Pennsylvania)H-Index: 4
Last. Ronald R. SalemH-Index: 30
view all 55 authors...
Abstract Background The association between intraoperative estimated blood loss and outcomes after pancreatoduodenectomy has, thus far, been rarely explored. Methods In total, 7,706 pancreatoduodenectomies performed at 18 international institutions composing the Pancreas Fistula Study Group were examined (2003–2020). High estimated blood loss (>700 mL) was defined as twice the median. Propensity score matching (1:1 exact-match) was employed to adjust for variables associated with high estimated ...
Source
#1Fabio Casciani (UPenn: University of Pennsylvania)H-Index: 3
#2Claudio Bassi (University of Verona)H-Index: 111
Last. Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 67
view all 3 authors...
Abstract Background Despite abundant, high-level scientific evidence, there is no consensus regarding the prevention, mitigation, and management of clinically relevant pancreatic fistula after pancreatoduodenectomy. The aim of the present investigation is three-fold: (1) to analyze the multiple decision-making points for pancreatico-enteric anastomotic creation and fistula mitigation and management after pancreatoduodenectomy, (2) to reveal the practice of contemporary experts, and (3) to indica...
Source
#1Kjetil Søreide (University of Bergen)H-Index: 64
#2Ville Sallinen (UH: University of Helsinki)H-Index: 23
Last. Rowan W. Parks (Edin.: University of Edinburgh)H-Index: 54
view all 4 authors...
One of the most dreaded complications of pancreatic surgery is the development of a post-operative pancreatic fistula (POPF). Appropriate understanding of the underlying pathophysiology, risk factors and perioperative mechanisms may allow for better management and use of preventive measures. Several risk scores have been developed but none are perfect in predicting POPF risk. Recognized factors include those related to the patient, the pathology and perioperative care. Interventions such as use ...
Source
#1Savio G. Barreto (Flinders University)H-Index: 22
#2Norma B. Bulamu (Flinders University)H-Index: 4
Last. John A. Windsor (Auckland City Hospital)H-Index: 72
view all 12 authors...
Abstract Background Health care expenditure is increasing around the world and surgery is a major cause of financial hardship to patients and their families. Using pancreatoduodenectomy (PD), one of the most complex, morbid and costly operation as an example, this study aimed to identify the cost drivers of surgery, estimate relative contribution of these drivers, and derive and validate a cohort-specific cost forecasting tool. Methods Data on the costs of 1406 patients undergoing PD in three te...
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#1Maxwell T. Trudeau (UPenn: University of Pennsylvania)H-Index: 4
#2Laura Maggino (UPenn: University of Pennsylvania)H-Index: 12
Last. Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 67
view all 9 authors...
Abstract Background Intraoperative drain use for pancreatoduodenectomy (PD) has been practiced in an unconditional, binary manner (placement/no-placement). Alternatively, dynamic drain management has been introduced, incorporating the Fistula Risk Score (FRS) and drain fluid amylase (DFA) analysis, to mitigate clinically-relevant pancreatic fistula (CR-POPF). Study Design An extended experience with dynamic drain management was employed at a single institution for 400 consecutive PDs (2014-2019)...
Source
#1Tommaso Giuliani (University of Verona)H-Index: 4
#2Stefano Andrianello (University of Verona)H-Index: 15
Last. Roberto Salvia (University of Verona)H-Index: 57
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Abstract Background Scores predicting postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) mainly use intraoperative predictors. The aim of this study is to investigate the role of pancreatic exocrine function expressed by fecal elastase (FE-1) as preoperative predictor of POPF. Methods Patients scheduled for PD at the Department of General and Pancreatic Surgery, University of Verona Hospital, from April 2017 to July 2018 were prospectively enrolled. FE-1 was measured in a...
Source
#1Kjetil SøreideH-Index: 64
#2Andrew J. HealeyH-Index: 1
Last. Rowan W. Parks (Edin.: University of Edinburgh)H-Index: 54
view all 4 authors...
Abstract Background The most hazardous complication to pancreatic surgery is the development of a post-operative pancreatic fistula (POPF). Appropriate understanding of the underlying pathophysiology, risk factors and perioperative mechanisms may allow for better management and use of preventive measures. Methods Systematic literature search using the English PubMed literature up to April 2019, with emphasis on the past 5 years. Results Several risk scores have been developed but none are perfec...
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