Factors affecting readmission after pancreaticoduodenectomy.
ABSTRACT PD continues to be associated with a high rate of failed discharges, despite significant improvements in techniques and postoperative care at high-volume centers. Even in the best hands, 1 in 5 patients undergoing PD can be expected to require readmission in the early postoperative period. Efforts to minimize readmissions must be aimed at identifying high-risk patients, addressing patient expectations, establishing patient care plans, and using outpatient resources to address anticipated problems and complications.
SourceAvailable from: nih.gov[Show abstract] [Hide abstract]
ABSTRACT: Between 1969 and 1986, 88 patients had a Whipple resection for adenocarcinoma of the pancreas (N = 50), ampulla (N = 19), distal bile duct (N = 10), and duodenum (N = 9). Forty-nine patients were men, 39 were women, and the mean age was 58 years (range: 34-84 years). The patients were divided into two groups on the basis of two different time periods: those operated on from 1969 to 1980 (N = 41) and those operated on from 1981 to 1986 (N = 47). There were no significant differences between the two groups in terms of mean age, sex distribution, duration of symptoms before presentation, or mean weight loss. Likewise, preoperative laboratory data were similar for both groups of patients. In addition, mean tumor size for patients with pancreatic cancer (3.5 cm vs. 3.2 cm) and patients with nonpancreatic periampullary cancer (1.9 cm vs. 2.2 cm) was similar in both groups, as was the incidence of positive lymph nodes. Among the 41 patients operated on during the first period, hospital morbidity and mortality rates were 59% and 24%, respectively. In contrast, hospital morbidity and mortality rates were 36% and 2%, respectively, among the 47 patients operated on during the recent period. During the recent period, more Whipple procedures were performed each year (7.8 vs. 3.4) and by fewer surgeons (3.4 operations/surgeon vs. 1.9 operations/surgeon). In addition, between 1981 and 1986, there were fewer total pancreatectomies (9% vs. 39%), fewer vagotomies (26% vs. 76%), and more pyloric-preserving procedures (30% vs. 0) performed compared with the earlier period. During the recent period, mean operative time (7.8 vs. 9.0 hours), mean estimated blood loss (1694 vs. 3271 mL), and mean intraoperative blood replacement (3.6 vs. 6.3 units) were all significantly less than in the earlier period. These findings suggest that the recent decline in operative morbidity and mortality may be due to fewer surgeons performing more Whipple resections in less time and with less blood loss. The actuarial 5-year survival rate for the 38 patients with nonpancreatic periampullary cancer was 34%. Surprisingly, the actuarial 5-year survival rate among the 50 patients with pancreatic cancer was 18%. Moreover, in the absence of positive lymph node involvement, the 5-year actuarial survival rate among patients with pancreatic cancer was 48%. No explanation is obvious for the improvement in survival among patients with pancreatic cancer.Annals of Surgery 10/1987; 206(3):358-65. DOI:10.1097/00000658-198709000-00014 · 7.19 Impact Factor
[Show abstract] [Hide abstract]
ABSTRACT: The authors reviewed the pathology, complications, and outcomes in a consecutive group of 650 patients undergoing pancreaticoduodenectomy in the 1990s. Pancreaticoduodenectomy has been used increasingly in recent years to resect a variety of malignant and benign diseases of the pancreas and periampullary region. Between January 1990 and July 1996, inclusive, 650 patients underwent pancreaticoduodenal resection at The Johns Hopkins Hospital. Data were recorded prospectively on all patients. All pathology specimens were reviewed and categorized. Statistical analyses were performed using both univariate and multivariate models. The patients had a mean age of 63 +/- 12.8 years, with 54% male and 91% white. The number of resections per year rose from 60 in 1990 to 161 in 1995. Pathologic examination results showed pancreatic cancer (n = 282; 43%), ampullary cancer (n = 70; 11%), distal common bile duct cancer (n = 65; 10%), duodenal cancer (n = 26; 4%), chronic pancreatitis (n = 71; 11%), neuroendocrine tumor (n = 31; 5%), periampullary adenoma (n = 21; 3%), cystadenocarcinoma (n = 14; 2%), cystadenoma (n = 25; 4%), and other (n = 45; 7%). The surgical procedure involved pylorus preservation in 82%, partial pancreatectomy in 95%, and portal or superior mesenteric venous resection in 4%. Pancreatic-enteric reconstruction, when appropriate, was via pancreaticojejunostomy in 71% and pancreaticogastrostomy in 29%. The median intraoperative blood loss was 625 mL, median units of red cells transfused was zero, and the median operative time was 7 hours. During this period, 190 consecutive pancreaticoduodenectomies were performed without a mortality. Nine deaths occurred in-hospital or within 30 days of operation (1.4% operative mortality). The postoperative complication rate was 41%, with the most common complications being early delayed gastric emptying (19%), pancreatic fistula (14%), and wound infection (10%). Twenty-three patients required reoperation in the immediate postoperative period (3.5%), most commonly for bleeding, abscess, or dehiscence. The median postoperative length of stay was 13 days. A multivariate analysis of the 443 patients with periampullary adenocarcinoma indicated that the most powerful independent predictors favoring long-term survival included a pathologic diagnosis of duodenal adenocarcinoma, tumor diameter <3 cm, negative resection margins, absence of lymph node metastases, well-differentiated histology, and no reoperation. This single institution, high-volume experience indicates that pancreaticoduodenectomy can be performed safely for a variety of malignant and benign disorders of the pancreas and periampullary region. Overall survival is determined largely by the pathology within the resection specimen.Annals of Surgery 09/1997; 226(3):248-57; discussion 257-60. DOI:10.1097/00000658-199709000-00004 · 7.19 Impact Factor
[Show abstract] [Hide abstract]
ABSTRACT: Readmission rates after pancreaticoduodenectomy (PD) for malignant diseases have a significant impact on survival rate. Identification of risk factors for readmission may improve discharge plans and postoperative care. Data exist on the morbidity and mortality of patients undergoing PD, but there are few reports about hospital readmissions after this procedure. Our aims were to evaluate the proportion and reasons for readmissions after PD for malignant diseases, the factors influencing readmissions, and to analyze the relationship between readmission rate and survival rate. Four hundred and thirty-six patients, who had undergone PD for malignant diseases in our centre from October 1999 to October 2009, a 10-year period, excluding perioperative (30-day) mortality, were identified. All readmissions within 1 year following PD were analyzed with respect to timing, location, reasons for readmission and outcome. We reviewed the hospitalization and readmissions for patients undergoing PD, and compared patients requiring readmission to patients that did not require readmission. One hundred and forty-five patients (33.26%) were readmitted within 1 year following PD, for further treatment or complications. In those cases, diagnoses associated with high rates of readmission included radiation and/or chemotherapy (48.96%), progression of disease (11.72%), infection (11.72%), gastrointestinal dysfunction/obstruction (6.20%), surgery-related complications (2.76%) and pain (4.14%). The proportion of T4 in readmission group was lower than no readmission group (P < 0.05). The proportion of node positive cases in readmission group was much higher than no readmission group (P < 0.01). The number of readmission for complications reduced gradually in the first three months, and reached a second peak in the sixth and seventh month. Median survival was lower for the readmission group compared with the no readmission group (21 versus 46 months, P = 0.024). These results may assist in both anticipating and facilitating postoperative care as well as managing patient expectations.Chinese medical journal 04/2011; 124(7):1022-5. · 1.02 Impact Factor