Pancreatectomy Demonstration Project ACS-NSQIP UT 7-22-12web2.facs.org/download/Pitt.pdf · Henry A. Pitt, M.D. Surgeon Champion Indiana University Hospital PANCREATECTOMY Demonstration
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Henry A. Pitt, M.D.Surgeon Champion
Indiana University Hospital
PANCREATECTOMYDemonstration Project
ACS-NSQIP National ConferenceSalt Lake City – July 22, 2012
Pancreatectomy Project
GOALS• Evaluate the ability of pancreatic surgeons and
SCRs to document and record new variables
• Initiate a registry for minimally invasive
pancreatic surgery
• Determine the influence of new variables on
serious morbidity and pancreatectomy-specific
outcomes
Pancreatectomy Project
UPDATE• Started November 1, 2011
• 35 Procedure Targeted hospitals
• 25 submitted first 3 months data
• 523 patients – pancreatic surgery
• 21 mean cases (2-97 range) 13 median
• Patient characteristics – representative
• 1.2% overall mortality
Pancreatectomy Project
OUTCOMES*
*Parikh et al HPB 2010;12:488-97
0
5
10
15
20
25
30
35
Mortality SeriousMorbidity
OveralMorbidity
Perc
ent
Pancreatectomy Project
QUESTIONS
• Jaundice
• Stents
• Neoadjuvant rx
• Min invas surg
• Vascular resection
• Panc reconstruct
• GI reconstruct
• Drain management
Pancreatectomy Project
OUTCOMES• ACS-NSQIP
MortalitySerious morbidityOverall morbidity
• Pancreatectomy specificPancreatic fistulaDelayed gastric emptyingPercutaneous drainage
Pancreatectomy Project
ISSUES
• Incomplete data
Type of stent
Duct size
Gland texture
Drain amylase
• Surgeon cooperation
Dictation
Ordering amylase
• Learning curve
Webinars
• PancreatoduodenectomyPylorus preservationClassic Whipple
• Distal pancreatectomySplenectomySplenic preservation
• Total pancreatectomy• Enucleation
PPPD
DP + S
Pancreatectomy Project
OPERATION TYPE
Pancreatectomy Project
OPERATION TYPE
0
10
20
30
40
50
60
70
80
Whipple Distal Total Enucleation
Perc
ent
Pancreatectomy Project
PREOPERATIVE VARIABLES• Obstructive jaundice
History – 2 monthsPhysical examT. bili > 2.0 mg/dl
• Biliary stentEndoscopicPercutaneous
• NeoadjuvantChemotherapy – 90dRadiation – 90d
Jaundice
Pancreatectomy Project
PREOP VARIABLES
010
20
30
4050
60
7080
Jaundice Stents Chemo RT
*
Perc
ent
* Whipple patients
*
0
5
10
15
20
25
SuperficialSSI
Organ SpaceSSI
PercutaneousDrain
No Stent
Pancreatectomy Project
STENT - INFECTIONSPe
rcen
t
Stent* p<0.01 vs No Stent
*
**
0
5
10
15
20
25
30
35
SuperficialSSI
Organ SpaceSSI
PercutaneousDrain
No RT
Pancreatectomy Project
RADIATION - INFECTIONSPe
rcen
t
RT* p<0.01 vs No RT*
NS NS
Pancreatectomy Project
SURGERY TYPE• Open• Minimally invasive
LaparoscopicHand-assistedLap convertedRoboticRobotic convertedHybrid
Pancreatectomy Project
MIN INVASIVE SURG
0
5
10
15
20
25
30
35
40
Whipple Distal Enucleation
N=11
N=36
N=6
Perc
ent
0
5
10
15
20
25
30
35
40
Whipple Distal
Open
Pancreatectomy Project
MIN INVASIVE – PANC FISTPe
rcen
t
Min Invasive* p<0.01 vs Open
*
Pancreatectomy Project
INTRAOPERATIVE VARIABLES
• Panc duct size< 3 mm3-6 mm> 6 mm
• Panc gland textureSoftIntermediateHard
Duct Size
Whipple
0
10
20
30
40
50
60
<3 3-6 >6 Soft Interm Hard
Pancreatectomy Project
DUCT SIZE – GLAND TEXTPe
rcen
t
Pancreatectomy Project
INTRAOPERATIVE VARIABLES
• Vasc ResectionVein – PV, SMVArtery – celiac,
HA, SMA
• Panc reconstructionPJ – invaginationPJ – duct-to-mucosaPanc gastrostomy
PV Resection
Invagination
0102030405060708090
100
None Venous Arterial
Pancreatectomy Project
VASCULAR RESECTIONPe
rcen
t
Pancreatectomy Project
PANCREATIC ANASTOMOSIS
0
10
20
30
40
50
60
70
80
PJ Duct-to-Mucosa
PJ In-vagination
Panc Gastros-tomy
Perc
ent
Pancreatectomy Project
INTRAOPERATIVE VARIABLES• Intest reconstr
GastrojejunostomyDuodenojejunostomyAntecolicRetrocolic
• DrainsPanc anastamosisBiliary anastamosisBoth
Whipple
Pancreatectomy Project
POSTOPERATIVE OUTCOMES• Pancreatic fistula
Drain remains > 7dAmylase > 3xPerc drainageReoperation
• Perc drainageamylase
PusBileOther
*
*Fluid collection
Perc drainage
Pancreatectomy Project
POSTOP OUTCOMES
0
5
10
15
20
PancreaticFistula
OSISSI
PercDrainage
Reoper-ation
Perc
ent
0
5
10
15
20
25
30
Panc Fistula Reoperation
No Drain
Pancreatectomy Project
DRAIN – PANC FISTULAPe
rcen
t
Drain* p<0.01 vs No Drain
*
*
Pancreatectomy Project
DELAYED GASTRIC EMPTYING
• G-tube > POD 7
DGE
• NG > POD 7
• NG reinserted> POD 7
• No oral intakeby POD 14 0
10
20
30
Ante Retro
*p<0.01 *Pe
rcen
t
Pancreatectomy Project
LOS - READMISSIONS• Length of Stay
Whipple – 11.8 d mean– 9.0 d median
Distal – 8.1 d mean– 6.0 d median
• Readmissions16.1% 30-day77.6% related
• New data on the influence of pre-,
intra- and postoperative variables
on procedure-specific outcomes
• New registry for minimally
invasive pancreatic surgery• Infrastructure for multicenter trials• Potential to improve outcomes
Pancreatectomy Project
CONCLUSIONS
• MalignantTypeT stageN stageM stage
• BenignType< 2 cm2-5 cm> 5 cm
Pancreatic cancer
Serous cystadenoma
Pancreatectomy Project
PATHOLOGY
• Continue Demonstration Project
• Improve data completeness
• Focus on drain amylase
• Add more institutions
• Consider revising variables
• Consider adding pathology
Pancreatectomy Project
NEXT STEPS
Pancreatectomy Project
THANK YOU• E. Molly Kilbane, RN
Coordination of the project
Communication with SCRs
• Bruce L. Hall, MD, PhD, MBA
ACS-NSQIP support
• Taylor Sohn Riall, MD, PhD
Analysis/interpretation of data
Pancreatectomy Project
THANK YOU• Baystate Med Cntr• Baptist Mem Memphis• Brigham & Womens Hosp• Emory University Hospital• Indiana University Hospital• Intermountain Med Cntr• IU Health-Methodist• Johns Hopkins Hospital• Kaiser Perm San Francisco• Massachusettes Gen Hosp• Oregon Health & Science• Penn State Hershey Med Cntr• Sacred Heart Med Cntr
• Stanford Hospital• Sutter Health Calif – PMC• Tampa General Hospital• The Ohio State Univ• Thomas Jefferson Univ• Univ of California – Irvine• Univ of California – San Diego• Univ of Iowa Hospital• Univ of Texas Med Branch• Wake Forest Univ Baptist• Washington Univ/Barnes Jewish• Winthrop University
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