Root cause analysis

Engineering

Pancreas

Cohort

Surgery

Cause of death

Pancreatic fistula

Pancreatectomy

Internal medicine

Medicine

Forensic engineering

Resection

General surgery

Disease

Mortality rate

Annals of Surgery

Objectives: Analyze a multicenter cohort of deceased patients after pancreatectomy in high-volume centers in France by performing a root-cause analysis (RCA) to define the avoidable mortality rate. Background: Despite undeniable progress in pancreatic surgery for over a century, postoperative outcome remains particularly worse and could be further improved. Methods: All patients undergoing pancreatectomy between January 2015 and December 2018 and died postoperatively within 90 days after were included. RCA was performed in 2 stages: the first being the exhaustive collection of data concerning each patient from preoperative to death and the second being blind analysis of files by an independent expert committee. A typical root cause of death was defined with the identification of avoidable death. Results: Among the 3195 patients operated on in 9 participating centers, 140 (4.4%) died within 90 days after surgery. After the exclusion of 39 patients, 101 patients were analyzed. The cause of death was identified in 90% of cases. After RCA, mortality was preventable in 30% of cases, mostly consequently to a preoperative assessment (disease evaluation) or a deficient postoperative management (notably pancreatic fistula and hemorrhage). An inappropriate intraoperative decision was incriminated in 10% of cases. The comparative analysis showed that young age and arterial resection, especially unplanned, were often associated with avoidable mortality. Conclusions: One-third of postoperative mortality after pancreatectomy seems to be avoidable, even if the surgery is performed in high volume centers. These data suggest that improving postoperative pancreatectomy outcome requires a multidisciplinary, rigorous, and personalized management.

Root-cause Analysis of Mortality After Pancreatic Resection (CARE Study)