Top

Published in:

01-09-2012 | Original Article

Risk of Morbidity and Mortality Following Hepato-Pancreato-Biliary Surgery

Authors: Peter J. Kneuertz, MD, Henry A. Pitt, MD, Karl Y. Bilimoria, MD, MPH, Jill P. Smiley, PhD, Mark E. Cohen, PhD, Clifford Y. Ko, MD, Timothy M. Pawlik, MD, MPH, PhD

Published in: Journal of Gastrointestinal Surgery | Issue 9/2012

Abstract

Introduction

Hepatic, pancreatic, and complex biliary (HPB) surgery can be associated with major morbidity and significant mortality. For the past 5 years, the American College of Surgeons–National Surgical Quality Improvement Program (ACS–NSQIP) has gathered robust data on patients undergoing HPB surgery. We sought to use the ACS–NSQIP data to determine which preoperative variables were predictive of adverse outcomes in patients undergoing HPB surgery.

Methods

Data collected from ACS–NSQIP on patients undergoing hepatic, pancreatic, or complex biliary surgery between 2005 and 2009 were analyzed (n = 13,558). Diagnoses and surgical procedures were categorized into 10 and eight groups, respectively. Seventeen preoperative clinical variables were assessed for prediction of 30-day postoperative morbidity and mortality. Multivariate logistic regression was utilized to develop a risk model.

Results

Of the 13,558 patients who underwent an HPB procedure, 7,321 (54%) had pancreatic, 4,881 (36%) hepatic, and 1,356 (10%) biliary surgery. Overall, 70.3% of patients had a cancer diagnosis. Post-operative complications occurred in 3,850 patients for an overall morbidity of 28.4%. Serious complications occurred in 2,522 (18.6%) patients; 366 patients died for an overall peri-operative mortality of 2.7%. Peri-operative outcome was associated with diagnosis and type of procedure. Hepatic trisectionectomy (5.8%) and total pancreatectomy (5.4%) had the highest 30-day mortality. Of the preoperative variables examined, age >74, dyspnea with moderate exertion, steroid use, prior cardiac procedure, ascites, and pre-operative sepsis were associated with morbidity and mortality (all P < 0.05).

Conclusions

While overall morbidity and mortality for HPB surgery are low, peri-operative outcomes are heterogeneous and depend on diagnosis, procedure type, and key clinical factors. By combining these factors, an ACS–NSQIP “HPB Risk Calculator” may be developed in the future to help better risk-stratify patients being considered for complex HPB surgery.

Grobmyer SR, Pieracci FM, Allen PJ, et al: Defining morbidity after pancreaticoduodenectomy: use of a prospective complication grading system. J Am Coll Surg 204:356-64, 2007PubMedCrossRef

Winter JM, Cameron JL, Campbell KA, et al: 1423 pancreaticoduodenectomies for pancreatic cancer: A single-institution experience. J Gastrointest Surg 10:1199-210; discussion 1210-1, 2006PubMedCrossRef

Ziegler KM, Nakeeb A, Pitt HA, et al: Pancreatic surgery: evolution at a high-volume center. Surgery 148:702-9; discussion 709-10, 2010PubMedCrossRef

Poon RT, Fan ST, Lo CM, et al: Improving perioperative outcome expands the role of hepatectomy in management of benign and malignant hepatobiliary diseases: analysis of 1222 consecutive patients from a prospective database. Ann Surg 240:698-708; discussion 708-10, 2004PubMed

Jarnagin WR, Gonen M, Fong Y, et al: Improvement in perioperative outcome after hepatic resection: analysis of 1,803 consecutive cases over the past decade. Ann Surg 236:397–406; discussion 406–7, 2002PubMedCrossRef

Dimick JB, Wainess RM, Cowan JA, et al: National trends in the use and outcomes of hepatic resection. J Am Coll Surg 199:31–8, 2004PubMedCrossRef

Teh SH, Diggs BS, Deveney CW, et al: Patient and hospital characteristics on the variance of perioperative outcomes for pancreatic resection in the United States: a plea for outcome-based and not volume-based referral guidelines. Arch Surg 144:713–21, 2009PubMedCrossRef

Nathan H, Segev DL, Mayo SC, et al: National trends in surgical procedures for hepatocellular carcinoma: 1998–2008. Cancer, 2011

Pawlik TM, Schulick RD, Choti MA: Expanding criteria for resectability of colorectal liver metastases. Oncologist 13:51–64, 2008PubMedCrossRef

10.

Asiyanbola B, Chang D, Gleisner AL, et al: Operative mortality after hepatic resection: are literature-based rates broadly applicable? J Gastrointest Surg 12:842–51, 2008PubMedCrossRef

11.

Hall BL, Hamilton BH, Richards K, et al: Does surgical quality improve in the American College of Surgeons National Surgical Quality Improvement Program: an evaluation of all participating hospitals. Ann Surg 250:363–76, 2009PubMed

12.

Aloia TA, Fahy BN, Fischer CP, et al: Predicting poor outcome following hepatectomy: analysis of 2313 hepatectomies in the NSQIP database. HPB : the official journal of the International Hepato Pancreato Biliary Association 11:510-5, 2009CrossRef

13.

Greenblatt DY, Kelly KJ, Rajamanickam V, et al: Preoperative factors predict perioperative morbidity and mortality after pancreaticoduodenectomy. Annals of surgical oncology 18:2126-35, 2011PubMedCrossRef

14.

Merkow RP, Bilimoria KY, Hall BL: Interpretation of the C-statistic in the context of ACS–NSQIP models. Ann Surg Oncol 18 Suppl 3:S295; author reply S296, 2011PubMedCrossRef

15.

Mann CD, Palser T, Briggs CD, et al: A review of factors predicting perioperative death and early outcome in hepatopancreaticobiliary cancer surgery. HPB (Oxford) 12:380–8, 2010CrossRef

16.

Gawande AA, Kwaan MR, Regenbogen SE, et al: An Apgar score for surgery. J Am Coll Surg 204:201-8, 2007PubMedCrossRef

17.

Hill JS, Zhou Z, Simons JP, et al: A simple risk score to predict in-hospital mortality after pancreatic resection for cancer. Ann Surg Oncol 17:1802–7, 2010PubMedCrossRef

18.

Cannon RM, Martin RC, Callender GG, et al: Safety and efficacy of hepatectomy for colorectal metastases in the elderly. J Surg Oncol 104:804–8, 2011PubMedCrossRef

19.

Reddy SK, Barbas AS, Turley RS, et al: Major liver resection in elderly patients: a multi-institutional analysis. J Am Coll Surg 212:787–95, 2011PubMedCrossRef

20.

Riall TS, Reddy DM, Nealon WH, et al: The effect of age on short-term outcomes after pancreatic resection: a population-based study. Ann Surg 248:459–67, 2008PubMed

21.

Pitt HA, Kilbane M, Strasberg SM, et al: ACS–NSQIP has the potential to create an HPB–NSQIP option. HPB (Oxford) 11:405–13, 2009CrossRef

22.

Finks JF, Osborne NH, Birkmeyer JD: Trends in hospital volume and operative mortality for high-risk surgery. N Engl J Med 364:2128-37, 2011PubMedCrossRef

Title: Risk of Morbidity and Mortality Following Hepato-Pancreato-Biliary Surgery
Authors: Peter J. Kneuertz, MD
Henry A. Pitt, MD
Karl Y. Bilimoria, MD, MPH
Jill P. Smiley, PhD
Mark E. Cohen, PhD
Clifford Y. Ko, MD
Timothy M. Pawlik, MD, MPH, PhD
Publication date: 01-09-2012
Publisher: Springer-Verlag
Published in: Journal of Gastrointestinal Surgery / Issue 9/2012
Print ISSN: 1091-255X
Electronic ISSN: 1873-4626
DOI: https://doi.org/10.1007/s11605-012-1938-y

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Risk of Morbidity and Mortality Following Hepato-Pancreato-Biliary Surgery

Abstract

Introduction

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Introduction

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 9/2012

Meta-analysis of Prospective Randomized Studies Comparing Single-Incision Laparoscopic Cholecystectomy (SILC) and Conventional Multiport Laparoscopic Cholecystectomy (CMLC)

Personalized Therapy: Prognostic Factors in Gastrointestinal Stromal Tumor (GIST)

Refinement of Minimally Invasive Esophagectomy Techniques After 15 Years of Experience

Salvage Liver Transplantation for Hepatic Gas Gangrene

Hemorrhagic Hepatic Cyst: Report of a Case and Review of the Literature with Emphasis on Clinical Approach and Management

Magnetically Anchored Cautery Dissector Improves Triangulation, Depth Perception, and Workload During Single-Site Laparoscopic Cholecystectomy