S. Narayanan1, A. N. Martin1, F. E. Turrentine1, T. W. Bauer1, R. B. Adams1, V. M. Zaydfudim1 1University Of Virginia,Department Of Surgery,Charlottesville, VA, USA
Introduction:
Safety of pancreaticoduodenectomy has improved significantly in the past two decades. Current inpatient and 30-day mortality rates are low. However, incidence and causes of 90-day and 1-year mortality are poorly defined and largely unexplored.
Methods:
All patients who had pancreaticoduodenectomy between 2007 and 2016 were included in this single institution retrospective cohort study. Distributions of postoperative pancreatectomy-specific morbidity and cause-specific mortality were compared between early (within 90-days) and late (91-365 days) post-operative recovery period.
Results:
A total of 552 pancreaticoduodenectomies were performed during the study period. Clinically significant pancreatic leak (11.8% versus 0%) and intra-abdominal abscess not related to pancreatic leak (4.0% versus 0.4%) were more common during early rather than late post-operative period (both p<0.001). Proportion of re-operations were higher in early compared to late post-operative period (6.5% versus 3.8%, respectively, p=0.041). Mortality at 30, 90, 180, and 365 days following pancreaticoduodenectomy was 6 (1.1%), 20 (3.6%), 45 (8.2%), and 90 (16.3%) patients, respectively. Causes of early and late mortality varied significantly (p<0.001). The most common cause of death within 90 days was due to intra-abdominal infection, sepsis and multiple system organ failure in 10 (50%) patients, followed by post-pancreatectomy hemorrhage in 4 patients (20%), and cardiopulmonary arrest from myocardial infarction or pulmonary embolus in 3 (15%) patients. In contrast, recurrent cancer was the most common cause of death in 45 (64%) patients during the late post-operative period between 91 and 365 days. Mortality from failure to thrive and debility, which was most frequently associated with delayed gastric emptying and failure of nutritional recovery, was similar between early (within 90-days) and late (91-365 days) post-operative periods (15% versus 16%, p=0.856).
Conclusion:
A majority of quality improvement initiatives in patients selected for pancreaticoduodenectomy have focused on reduction of technical complications and improvement of early post-operative mortality. Further reduction in post-operative mortality after pancreaticoduodenectomy can be achieved by improving patient selection, mitigating post-operative malnutrition, and optimizing preoperative cancer staging and management strategies.