Surgeon experience contributes to improved outcomes in pancreatoduodenectomies at high risk for fistula development.

Published on Apr 1, 2021in Surgery3.982
· DOI :10.1016/J.SURG.2020.11.022
Fabio Casciani3
Estimated H-index: 3
(UPenn: University of Pennsylvania),
Maxwell T. Trudeau4
Estimated H-index: 4
(UPenn: University of Pennsylvania)
+ 52 AuthorsJohn W. Kunstman18
Estimated H-index: 18
Abstract Background Pancreatoduodenectomies at high risk for clinically relevant pancreatic fistula are uncommon, yet intimidating, situations. In such scenarios, the impact of individual surgeon experience on outcomes is poorly understood. Methods The fistula risk score was applied to identify high-risk patients (fistula risk score 7–10) from 7,706 pancreatoduodenectomies performed at 18 international institutions (2003–2020). For each case, surgeon pancreatoduodenectomy career volume and years of practice were linked to intraoperative fistula mitigation strategy adoption and outcomes. Consequently, best operative approaches for clinically relevant pancreatic fistula prevention and best performer profiles were identified through multivariable analysis models. Results Eight hundred and thirty high-risk pancreatoduodenectomies, performed by 64 surgeons, displayed an overall clinically relevant pancreatic fistula rate of 33.7%. Clinically relevant pancreatic fistula rates decreased with escalating surgeon career pancreatoduodenectomy (–49.7%) and career length (–41.2%; both P Conclusion Surgeon experience is a key contributor to achieve better outcomes after high-risk pancreatoduodenectomy. Surgeons can improve their performance in these challenging situations by employing pancreatojejunostomy reconstruction, omitting prophylactic octreotide, and minimizing blood loss.
#1Maxwell T. Trudeau (UPenn: University of Pennsylvania)H-Index: 4
#2Fabio Casciani (UPenn: University of Pennsylvania)H-Index: 3
Last. Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 67
view all 25 authors...
OBJECTIVE To investigate the role of intraoperative EBL on development of CR-POPF after pancreatoduodenectomy (PD). BACKGROUND Minimizing EBL has been shown to decrease transfusions and provide better perioperative outcomes in PD. EBL is also felt to be influential on CR-POPF development. METHODS This study consists of 5534 PDs from a 17-institution collaborative (2003-2018). EBL was progressively categorized (≤150 mL; 151-400 mL; 401-1,000 mL; >1,000 mL). Impact of additive EBL was assessed usi...
#1J. Gregory Modrall (UTSW: University of Texas Southwestern Medical Center)H-Index: 25
#2Shirling Tsai (UTSW: University of Texas Southwestern Medical Center)H-Index: 16
Last. Eric B. Rosero (UTSW: University of Texas Southwestern Medical Center)H-Index: 23
view all 8 authors...
Abstract Objective The outcomes for common vascular operations, such as carotid endarterectomy (CEA), are associated with surgeon volume. However, the number of operations associated with an improved stroke or death rate for CEA is not known. The objective of the current study was to define the annual surgeon volume of CEAs that is associated with a lower risk of stroke or death rate. Methods The Nationwide Inpatient Sample was analyzed to identify patients undergoing CEA between 2003 and 2009. ...
#1Katiuscha Merath (The Ohio State University Wexner Medical Center)H-Index: 21
#2Rittal Mehta (The Ohio State University Wexner Medical Center)H-Index: 17
Last. Timothy M. Pawlik (The Ohio State University Wexner Medical Center)H-Index: 121
view all 9 authors...
Background While patient- and hospital-level factors affecting outcomes of patients undergoing pancreatoduodenectomy (PD) have been well described separately, the relative impact of these factors on in-hospital mortality has not been comprehensively assessed.
#1Stefano Andrianello (University of Verona)H-Index: 15
#2Giovanni Marchegiani (University of Verona)H-Index: 32
Last. Claudio Bassi (University of Verona)H-Index: 111
view all 12 authors...
Importance The operative scenarios with the highest postoperative pancreatic fistula (POPF) risk represent situations in which fistula prevention and mitigation strategies have the strongest potential to affect surgical outcomes after pancreaticoduodenectomy. Evidence from studies providing risk stratification is lacking. Objective To investigate whether pancreaticojejunostomy (PJ) or pancreaticogastrostomy (PG), both with externalized transanastomotic stent, is the best reconstruction method fo...
#1Laura Maggino (UPenn: University of Pennsylvania)H-Index: 12
#2Jason B. Liu (U of C: University of Chicago)H-Index: 13
Last. Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 67
view all 6 authors...
Abstract Background The association between higher surgical volume and better perioperative outcomes after pancreatectomy has been extensively demonstrated. However, how different notions of experience impact outcomes of surgeons operating within high-quality scenarios remains unclear. Methods Self-reported experience parameters from ACS-NSQIP HPB-Collaborative surgeons were merged with 2014–2016 ACS-NSQIP clinical data. The association of various experience parameters with outcomes was investig...
#1Thomas F. Seykora (UPenn: University of Pennsylvania)H-Index: 6
#2Brett L. Ecker (UPenn: University of Pennsylvania)H-Index: 19
Last. Charles M. VollmerH-Index: 67
view all 18 authors...
OBJECTIVE:The aim of this study was to elucidate the impact of intraoperative blood loss on outcomes following pancreatoduodenectomy (PD). BACKGROUND:The negative impact of intraoperative blood loss on outcomes in PD has long been suspected but not well characterized, particularly those factors that may be within surgeons' control. METHODS:From 2001 to 2015, 5323 PDs were performed by 62 surgeons from 17 institutions. Estimated blood loss (EBL) was discretized (0 to 300, 301 to 750, 751 to 1300,...
#1Mehdi El AmraniH-Index: 9
#2Guillaume Clément (university of lille)H-Index: 7
Last. Stéphanie TruantH-Index: 28
view all 8 authors...
OBJECTIVE: To evaluate the influence of hospital volume on failure-to-rescue (FTR) after pancreatectomy in France. BACKGROUND: There are growing evidences that FTR is an important source of postoperative mortality (POM) after pancreatectomy. However, few studies have analyzed the volume-FTR relationship following pancreatic surgery. METHODS: All patients undergoing pancreatectomy between 2012 and 2015 were included. FTR is defined as the 90-day POM rate among patients with major complications. A...
#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 38 authors...
Objective:The aim of this study was to identify the optimal fistula mitigation strategy following pancreaticoduodenectomy.Background:The utility of technical strategies to prevent clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreatoduodenectomy (PD) may vary by the circ
Importance Identifying high-performing surgical valve centers with the best surgical outcomes is challenging. Hospital surgical volume is a frequently used surrogate for outcomes. However, its ability to distinguish low-performing and high-performing hospitals remains unknown. Objective To examine the association of hospital procedure volume with hospital performance for aortic and mitral valve (MV) surgical procedures. Design, Setting, and Participants Within an all-payer nationally representat...
#1Gregory T. Kennedy (UPenn: University of Pennsylvania)H-Index: 9
#2Matthew T. McMillan (UPenn: University of Pennsylvania)H-Index: 25
Last. Charles M. Vollmer (UPenn: University of Pennsylvania)H-Index: 67
view all 5 authors...
Background Experienced surgeons demonstrate improved pancreatoduodenectomy outcomes, but little is known about what distinguishes their practice. Furthermore, the concept of experience has been variably interpreted in the surgical literature. We investigated how 4 interpretations of experience influence pancreatoduodenectomy management decisions. Methods A survey assessing pancreatoduodenectomy practice patterns was distributed by 6 surgical societies. Regression analysis identified behaviors as...
Cited By4
#1Taiichi Wakiya (Hirosaki University)H-Index: 8
#2Keinosuke Ishido (Hirosaki University)H-Index: 11
Last. Yoshihiro Sasaki (Hirosaki University)H-Index: 9
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Massive intraoperative blood loss (IBL) negatively influence outcomes after surgery for pancreatic ductal adenocarcinoma (PDAC). However, few data or predictive models are available for the identification of patients with a high risk for massive IBL. This study aimed to build a model for massive IBL prediction using a decision tree algorithm, which is one machine learning method. One hundred and seventy-five patients undergoing curative surgery for resectable PDAC at our facility between January...
#1Lisa Suzanne Brubaker (BCM: Baylor College of Medicine)H-Index: 3
#2Fabio Casciani (University of Verona)H-Index: 3
Last. Chad G. Ball (U of C: University of Calgary)H-Index: 55
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Abstract null null Background null Intraperitoneal drain placement decreases morbidity and mortality in patients who develop a clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreaticoduodenectomy (PD). It is unknown whether multiple drains mitigate CR-POPF better than a single drain. We hypothesize that multiple drains decrease the complication burden more than a single drain in cases at greater risk for CR-POPF. null null null Methods null The Fistula Risk Score (FRS...
#1Jae-Woo Ju (Seoul National University Hospital)
#2So Jung Park (Seoul National University Hospital)
Last. Jin-Young Jang (Seoul National University Hospital)H-Index: 55
view all 8 authors...
BACKGROUND Although perioperative hypothermia was found to be associated with gastrointestinal anastomotic leakage in preclinical studies, its association with postoperative pancreatic fistula (POPF) following pancreaticoduodenectomy was never evaluated. We investigated the association between intraoperative hypothermia and clinically relevant (CR)-POPF following pancreaticoduodenectomy. METHODS We retrospectively reviewed 2163 consecutive patients who underwent pancreaticoduodenectomy during 20...
#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...
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