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