R. T. Nagle1, H. Lavu1, E. L. Rosato1, C. J. Yeo1, J. M. Winter1 1Thomas Jefferson University,Department Of Surgery,Philadelphia, PA, USA
Introduction: Pancreatectomy is associated with a high complication rate of approximately 40%, and a mortality rate ranging from 1-10%. While many specific complications have been extensively studied, postoperative pneumonia has received relatively little attention.
Methods: We performed a single-institution, IRB-approved retrospective analysis of patients who underwent pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) from 2002 to 2014. Patient data were extracted from electronic medical records. Postoperative pneumonia was defined here as a radiographic finding of an infiltrate followed by antibiotic therapy. Pneumonia was further stratified by cause including ventilator-associated, aspiration, or community acquired. The incidence of post-pancreatectomy pneumonia, predictive factors, and its impact on post-operative outcomes were determined.
Results: 1526 patients underwent a pancreatectomy, including 1090 PDs (71%) and 436 DPs (29%). There were a total of 47 (4.3%) and 11 (2.5%) cases of pneumonia, respectively. The majority of the pneumonias were attributed to aspiration (87.2% and 81.8% in the two cohorts). Pneumonias were graded using the Clavien-Dindo classification, and were more frequently severe (grades 4 or 5) in the PD group (55.3% vs 9.1% with DP, p=0.006). In the PD group, univariate predictors of postoperative pneumonia included male gender (odds ratio (OR) 2.7, p=0.003), age (OR 1.03, p=0.041), COPD (OR 5.0, p<0.001), smoking history (OR 2.0, p=0.022), delayed gastric emptying (DGE, OR 10.3, p<0.001), and persistent oxygen requirement on post-op day 3 (OR 4.4, p<0.001). In a multivariate model, COPD (OR 3.2, p=0.036), DGE (OR 9.1, p<0.001), and persistent oxygen requirement on post-op day 3 (OR 3.2, p=0.005) remained significant predictors. Pneumonia rates in patients who experienced ISGPS grades B and C DGE were particularly high (51.8%) compared with grade A or no DGE (8.67%, p<0.001). In the PD group, postoperative pneumonia was associated with a prolonged length of stay (median 18 days, vs 7 days in the absence of pneumonia, p<0.001) and an extremely high 90-day mortality (38.9% vs. 3.9% in the absence of pneumonia, p<0.001). In a multivariate regression model of 90-day mortality after PD (Table 1), postoperative pneumonia was the most robust predictor of postoperative death (OR 24.1, p<0.001).
Conclusion: Pneumonia following PD is an uncommon but highly morbid event, with a substantially increased risk of death. Patients with pre-existing pulmonary disease are at increased risk, and severe DGE may lead to postoperative pneumonia due to an elevated aspiration risk. These data underscore the importance of cautious dietary progression and aspiration precautions in these individuals.?
