Optimal Pancreatic Surgery: Are We Making Progress in North America?

OBJECTIVE: Our aims were to assess North American trends in the management of patients undergoing pancreatoduodenectomy (PD) and distal pancreatectomy (DP), and to quantify the delivery of optimal pancreatic surgery. BACKGROUND: Morbidity after pancreatectomy remains unacceptably high. Recent literature suggests that composite measures may more accurately define surgical quality. METHODS: The 2013 to 2017 American College of Surgeons National Surgical Quality Improvement Program Participant Use Files were queried to identify patients undergoing PD (N = 16,222) and DP (N = 7946). Patient, process, procedure, and 30-day postoperative outcome variables were analyzed over time. Optimal pancreatic surgery was defined as the absence of postoperative mortality, serious morbidity, percutaneous drainage, and reoperation while achieving a length of stay equal to or less than the 75th percentile (12 days for PD and 7 days for DP) with no readmissions. Risk-adjusted time-trend analyses were performed using logistic regression, and the threshold for statistical significance was P ≤ 0.05. RESULTS: The use of minimally invasive PD did not change over time, but robotic PD increased (2.5 to 4.2%; P < 0.001) and laparoscopic PD decreased (5.8% to 4.3%; P < 0.02). Operative times decreased (P < 0.05) and fewer transfusions were administered (P < 0.001). The percentage of patients with a drain fluid amylase checked on postoperative day 1 increased (P < 0.001), and a greater percentage of surgical drains were removed by postoperative day 3 (P < 0.001). Overall morbidity (P < 0.02), mortality (P < 0.05), and postoperative length of stay (P = 0.002) decreased. Finally, the rate of optimal pancreatic surgery increased for PD (53.7% to 56.9%; P < 0.01) and DP (53.3% to 58.5%; P < 0.001), and alspo for patients with pancreatic cancer (P < 0.01). CONCLUSIONS: From 2013 to 2017, pre, intra, and perioperative pancreatectomy processes have evolved, and multiple postoperative outcomes have improved. Thus, in 4 years, optimal pancreatic surgery in North America has increased by 3% to 5%.