Wande B Pratt

Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States

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Publications (21)80.38 Total impact

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    ABSTRACT: The Fistula Risk Score (FRS), a ten-point scale that relies on weighted influence of four variables, has been shown to effectively predict clinically relevant postoperative pancreatic fistula (CR-POPF) development and its consequences after pancreatoduodenectomy (PD). The proposed FRS demonstrated excellent predictive capacity; however, external validation of this tool would confirm its universal applicability. From 2001 to 2012, 594 PDs with pancreatojejunostomy reconstructions were performed at three institutions. POPFs were graded by International Study Group on Pancreatic Fistula standards as grades A, B, or C. The FRS was calculated for each patient, and clinical outcomes were evaluated across four discrete risk zones as described in the original work. Receiver operator curve analysis was performed to judge model validity. One hundred forty-two patients developed any sort of POPF, of which 68 were CR-POPF (11.4 % overall; 8.9 % grade B, 2.5 % grade C). Increasing FRS scores (0-10) correlated well with CR-POPF development (p < 0.001) with a C-statistic of 0.716. When segregated by discrete FRS-risk groups, CR-POPFs occurred in low-, moderate-, and high-risk patients, 6.6, 12.9, and 28.6 % of the time, respectively (p < 0.001). Clinical outcomes including complications, length of stay, and readmission rates also increased across risk groups. This multi-institutional experience confirms the Fistula Risk Score as a valid tool for predicting the development of CR-POPF after PD. Patients devoid of any risk factors did not develop a CR-POPF, and the rate of CR-POPF approximately doubles with each subsequent risk zone. The FRS is validated as a strongly predictive tool, with widespread applicability, which can be readily incorporated into common clinical practice and research analysis.
    Journal of Gastrointestinal Surgery 09/2013; · 2.36 Impact Factor
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    ABSTRACT: The Post-operative Morbidity Index (PMI) is a quantitative utility measure of a complication burden created by severity weighting. The Fistula Risk Score (FRS) is a validated model that predicts whether a patient will develop a post-operative pancreatic fistula (POPF). These novel tools might provide further discrimination of the ISGPF grading system. From 2001 to 2012, 1021 pancreaticoduodenectomies were performed at four institutions. POPFs were categorized by ISGPF standards. PMI scores were calculated based on the Modified Accordion Severity Grading System. FRS scores were assigned according to the relative influence of four recognized factors for developing a clinically relevant POPF (CR-POPF). In total, 231 patients (22.6%) developed a POPF, of which 54.1% were CR-POPFs. The PMI differed significantly between the ISGPF grades and patients with no or non-fistulous complications (P < 0.001). 64.9% of POPFs and 84.0% of CR-POPFs contributed the highest Accordion grade to the PMI. Overall, the FRS correlated well with PMI (R(2) = 0.81, P < 0.001). These data quantitatively reinforce the ISGPF grades that were developed qualitatively around the concept of clinical severity. CR-POPFs usually reflect the patient's highest Accordion score whereas biochemical POPFs are often superseded. The correlation between FRS and PMI indicates that risk factors for a fistula contribute to overall pancreaticoduodenectomy morbidity.
    HPB 07/2013; · 1.94 Impact Factor
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    ABSTRACT: BACKGROUND: The efficacy of pancreaticojejunal (P-J) anastomotic stents in preventing clinically relevant postoperative pancreatic fistulas (CR-POPF) after pancreatic resection is poorly understood. We sought to compare the outcomes of stented and nonstented patients in light of recognized risk-factors for the development of CR-POPF and to determine whether outcomes differed once there was a change in practice where use of stents was abandoned. METHODS: A total of 444 patients underwent proximal pancreatic resection with P-J reconstruction from 2001 to 2011. At the surgeon's discretion, a PJ stent (5- or 8-Fr Silastic tube) was placed in 59 patients (13.3%; 46 internal, 13 external). Demographics, comorbidities, and adjusted outcomes were evaluated between groups of nonstented (n = 385) and stented patients; these outcomes included a subgroup analysis of internally and externally stented patients. Risk factors for CR-POPF (International Study Group on Pancreatic Fistula grade B/C) development have been previously defined as soft gland, small duct size, high-risk pathology, or excessive blood loss (>1,000 mL). Outcomes were interpreted in reference to the risk factor profile (the number of absolute risk factors present; 0-4), and to the fistula risk score, a prospectively validated score which accurately predicts the risk and impact of pancreatic fistula based on these variables. RESULTS: Preoperative demographics of age, sex, body mass index, American Society of Anesthesiologists class, and physiologic and operative severity score for the enumeration of mortality and morbidity (ie, POSSUM) score were equivalent between cohorts. The CR-POPF risk-factor profile and fistula risk score were greater in stented patients (P < .01). When compared with nonstented patients, stented patients actually had greater rates of CR-POPF (29% vs 11%), major complications (29% vs 14%), greater mean duration of stay (13.7 days vs 9.6 days), and total costs ($33,594 vs $22,411; all P < .05). When high-risk cases were scrutinized, P-J stent use did not offer protection, as CR-POPF was uniformly more common when stents were used. Rates and severity of CR-POPF did not increase when the use of stents was abandoned, further implying that they did not confer protection from fistula development. Extended postoperative imaging was available for 23 stented patients. Of these, one-third of stents were retained past 6 weeks, and one-fourth beyond 6 months. Four patients required additional procedures to manage stent-related complications. CONCLUSION: The use of P-J stents does not decrease the incidence or severity of CR-POPF after proximal pancreatic resection, both overall and for high-risk scenarios. In some patients, P-J stents may lead to short- and long-term adverse outcomes.
    Surgery 01/2013; · 3.37 Impact Factor
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    ABSTRACT: BACKGROUND: Clinically relevant postoperative pancreatic fistulas (CR-POPF) are serious inherent risks of pancreatic resection. Preoperative CR-POPF risk assessment is currently inadequate and rarely disqualifies patients who need resection. The best evaluation of risk occurs intraoperatively, and should guide fistula prevention and response measures thereafter. We sought to develop a risk prediction tool for CR-POPF that features intraoperative assessment and reveals associated clinical and economic significance. STUDY DESIGN: Based on International Study Group of Pancreatic Fistula classification, recognized risk factors for CR-POPF (small duct, soft pancreas, high-risk pathology, excessive blood loss) were evaluated during pancreaticoduodenectomy. An optimal risk score range model, selected from 3 different constructs, was first derived (n = 233) and then validated prospectively (n = 212). Clinical and economic outcomes were evaluated across 4 ranges of scores (negligible risk, 0 points; low risk, 1 to 2; intermediate risk, 3 to 6; high risk, 7 to 10). RESULTS: Clinically relevant postoperative pancreatic fistulas occurred in 13% of patients. The incidence was greatest with excessive blood loss. Duct size <5 mm was associated with increased fistula rates that rose with even smaller ducts. These factors, together with soft pancreatic parenchyma and certain disease pathologies, afforded a highly predictive 10-point Fistula Risk Score. Risk scores strongly correlated with fistula development (p < 0.001). Notably, patients with scores of 0 points never developed a CR-POPF, while fistulas occurred in all patients with scores of 9 or 10. Other clinical and economic outcomes segregated by risk profile across the 4 risk strata. CONCLUSIONS: A simple 10-point Fistula Risk Score derived during pancreaticoduodenectomy accurately predicts subsequent CR-POPF. It can be readily learned and broadly deployed. This prediction tool can help surgeons anticipate, identify, and manage this ominous complication from the outset.
    Journal of the American College of Surgeons 11/2012; · 4.50 Impact Factor
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    ABSTRACT: Obstruction of the pancreatico-biliary (PB) drainage limb following major PB operations creates unique diagnostic and management dilemmas. We describe the etiology and prevalence, as well as diagnostic and therapeutic approaches for this challenging problem. Individuals with PB limb obstruction were identified from a cohort of 477 patients undergoing major PB resections or bypasses for benign and malignant (N = 265) diseases from September 2000 to January 2010. Their presentation, management, short-term outcomes, and survival were analyzed. Thirteen patients developed eventual PB limb obstruction with a mean time to presentation of 18.4 months (range 0.5-41.9), representing an overall adjusted incidence of 4%. Presenting symptoms were reflective of limb obstruction (elevated LFTs, jaundice, cholangitis, and pancreatitis). CT scans demonstrated dilation of the PB drainage limb in all 13 patients and evidence of intrahepatic biliary dilation in eight. Endoscopy was not valuable for either diagnostic or therapeutic purposes in the five patients evaluated in this manner. Percutaneous transhepatic biliary drainage (PTC) was pursued in six patients and provided definitive palliation in two, while three were temporized by this modality prior to a definitive operation, and it was employed postoperatively in another. Operative management occurred in 11 of 13 patients. Causative lesions were not accurately predicted by preoperative imaging and included adhesions, limb volvulus, abscess, malignant local recurrence, solitary metastatic disease, and carcinomatosis. Surgical interventions varied (five enteric bypasses, three adhesiolyses, two explorations, and one external limb venting). There were two perioperative mortalities, but limited morbidity otherwise (one myocardial infarction, one wound dehiscence, and one empyema from PTC placement). The median duration of postoperative hospital stay was 9 days, and no patient required readmission for further surgical management. No patients suffered subsequent recurrence of PB obstruction. In follow-up, nine of the remaining 11 patients are deceased with a median survival of 2.3 months (0.6-9.4 months). The other two are alive at a mean follow-up of 48 months. Although infrequent, PB limb obstruction occurs for a variety of reasons and most commonly in the setting of an original malignancy. Since numerous therapeutic modalities are available, an improved understanding of the condition is important in managing these complex patients. Decisive operative intervention accurately assesses the cause and extent of the problem and, for most presentations, provides definitive palliation with limited morbidity for this near-terminal event.
    Journal of Gastrointestinal Surgery 09/2010; 14(9):1414-21. · 2.36 Impact Factor
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    ABSTRACT: To evaluate pancreatic surgery as a model for high-acuity surgery in elderly patients for immediate and long-term outcomes, predictors of adverse outcomes, and hospital costs. Retrospective case series. University tertiary care referral center. Four hundred twelve consecutive patients who underwent pancreatic resection from October 1, 2001, through March 31, 2008, for benign and malignant periampullary conditions. Clinical outcomes were compared for elderly (> or = 75 years) and nonelderly patient cohorts. Quality assessment analyses were performed to show the differential impact of complications and resource utilization between the groups. The elderly cohort constituted one-fifth of all patients. Benchmark standards of quality were achieved in this group, including low operative mortality (1%). Despite higher patient acuity, clinical outcomes were comparable to those of nonelderly patients at a marginal cost increase (median, $2202 per case). Cost modeling analysis showed further that minor and moderate complications were more frequent but no more debilitating for elderly patients. Major complications, however, were far more threatening to older patients. In these cases, duration of hospital stay doubled, and invasive interventions were more commonly deployed. Quality standards for pancreatic resection in the elderly can--and should--mirror those for younger patients. Age-related care, including geriatric consultation, supplemental enteral nutrition, and early rehabilitation placement planning, can be designed to mitigate the impact of complications in the elderly and guarantee quality.
    Archives of surgery (Chicago, Ill.: 1960) 10/2009; 144(10):950-6. · 4.32 Impact Factor
  • W B Pratt, M P Callery, C M Vollmer
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    ABSTRACT: Pancreatic fistula is traditionally suspected on the basis of increased drain amylase activity. However, some patients have a low amylase level but later manifest clinical evidence of a fistula. This study investigated the prevalence and significance of these presentations. Severity of fistula was determined according to the International Study Group on Pancreatic Fistula criteria for 405 consecutive pancreatic resections. Latent fistulas, initially lacking amylase-rich effluent but ultimately clinically relevant (grades B or C), were examined to determine their impact and significance. Fistula of any extent occurred in 107 patients (26.4 per cent). Latent fistulas occurred in 20 patients (4.9 per cent of all resections, 18.7 per cent of all fistulas and 36 per cent of all clinically relevant fistulas). Initial amylase activity was consistently low (range 3-235 units/l), but these fistulas subsequently manifested clinical relevance (abdominal pain, radiographic evidence, fever, sinister effluent, wound infection). Latent presentations had twice the infection rate of evident fistulas, required more aggressive interventions, resulted in longer hospitalizations and incurred greater hospital costs. A considerable proportion of patients with pancreatic fistula do not initially demonstrate an amylase-rich effluent. These patients have significantly worse outcomes. In fistula definition, the clinical course is important as well as biochemical parameters.
    British Journal of Surgery 07/2009; 96(6):641-9. · 4.84 Impact Factor
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    ABSTRACT: Quality improvement in high-acuity surgery increasingly relies on clinical pathways to streamline patient care and to maximize cost-efficiency. Yet, it remains unclear whether immediate pre-operative hospitalization (non-elective resection) influences operative performance and to what extent it alters the post-operative course. Retrospective case series, cost analysis.University tertiary care referral centre. Four hundred and twelve consecutive pancreatic resections performed for benign and malignant disease between 2001 and 2008. Outcomes for both elective and non-elective operations were scrutinized, and correlated with deviations from our clinical Carepath for Pancreatic Resection. Observed-to-expected (O/E) morbidity ratios were calculated for each. Overall, 39 patients (10%) required immediate pre-operative hospitalization, 22 (56%) of which were transferred from another hospital. The most common indications were pancreatitis, gastric outlet obstruction, intractable abdominal pain and gastrointestinal bleeding. During a 1- to 2-week hospitalization, 51% of patients underwent endoscopic retrograde cholangio-pancreatography (ERCP), 36% were administered parenteral nutrition, 20% received antibiotics and 15% were transfused blood products. Yet, this pre-operative scenario, at a median cost of $7250 per patient, had no measurable impact on operative performance. Post-operatively, non-elective patients suffered more complications and a higher (O/E) ratio (1.00 vs. 0.93). These outcomes resulted in significantly more deviations from our carepath and an additional $7000 per non-elective case. Immediate pre-operative hospitalization has no meaningful impact on operative performance; yet, deviations from a standardized clinical pathway are far more likely after non-elective pancreatic resection, and result in more severe clinical and economic outcomes.
    HPB 02/2009; 11(1):57-65. · 1.94 Impact Factor
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    ABSTRACT: Although asymptomatic pancreatic lesions (APLs) are being discovered incidentally with increasing frequency, their true significance remains uncertain. Treatment decisions pivot off concerns for malignancy but at times might be excessive. To understand better the role of surgery, we scrutinized a spectrum of APLs as they presented to our surgical practice over defined periods. All incidentally identified APLs that were operated upon during the past 5 years were clinically and pathologically annotated. Among features evaluated were method/reason for detection, location, morphology, interventions, and pathology. For the past 2 years, since our adoption of the Sendai guidelines for cystic lesions, we scrutinized our approach to all patients presenting with APLs, operated upon or not. Over 5 years, APLs were identified most frequently during evaluation of: genitourinary/renal (16%), asymptomatic rise in liver function tests (LFTs; 13%), screening/surveillance (7%), and chest pain (6%). APLs occurred throughout the pancreas (body/tail 63%; head/uncinate 37%) with 48% being solid. One hundred ten operations were performed with no operative mortality including 89 resections (distal 57; Whipple 32) and 21 other procedures. Morbidity was equivalent or better than those cases performed for symptomatic lesions during the same time frame. During these 5 years, APLs accounted for 23% of all pancreatic resections we performed. In all, 22 different diagnoses emerged including non-malignant intraductal papillary mucinous neoplasm (IPMN; 17%), serous cystadenoma (14%), and neuroendocrine tumors (13%), while 6% of patients had >1 distinct pathology and 12% had no actual pancreatic lesion at all. Invasive malignancy was present 17% of the time, while carcinoma in situ or metastases was identified in an additional eight patients. Thus, the overall malignancy rate for APLs equals 24% and these patients were substantially older (68 vs 58 years; p = 0.003). An asymptomatic rise in LFTs correlated significantly (p = 0.009) with malignancy. Furthermore, premalignant pathology was found an additional 47% of the time. Seven patients ultimately chose an operation over continued observation for radiographic changes (mean 2.6 years), but none had cancer. In the last 2 years, we have evaluated 132 new patients with APLs, representing 47% of total referrals for pancreatic conditions. Nearly half were operated upon, with a 3:2 ratio of solid to cystic lesions. This differs significantly (p = 0.037) from the previous 3 years (2:3 ratio), reflecting tolerance for cysts <3 cm and side-branch IPMN. Surgery was undertaken more often when a solid APL was encountered (74%) than for cysts (32%). Some solid APLs were actually unresectable cancers. Due to anxiety, two patients requested an operation over continued observation, and neither had cancer. APLs occur commonly, are often solid, and reflect a spectrum of diagnoses. Sendai guidelines are not transferable to solid masses but have safely refined management of cysts. An asymptomatic rise in LFTs cannot be overlooked nor should a patient or doctor's anxiety, given the prevalence of cancer in APLs.
    Journal of Gastrointestinal Surgery 02/2009; 13(3):405-15. · 2.36 Impact Factor
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    ABSTRACT: The interplay between baseline physiology, operative performance, and postoperative recovery is poorly defined. We describe the beneficial effect of a successful operation on outcomes across the full spectrum of physiologic risk for an elective high-acuity procedure. Four hundred twelve consecutive pancreatic resections, performed between 2001 and 2008, were analyzed according to the Physiologic and Operative Severity Score for the Enumeration of Mortality and Morbidity. Baseline physiology was classified according to the Physiologic Severity Score: minor (< or = 16); intermediate (17 to 23); vulnerable (> or = 24). Surgical performance was assigned by the Operative Severity Score: class I (< or = 14); class II (15 to 17); class III (> or = 18). Physiologic and operative predictions were independently correlated with actual clinical and economic outcomes and then merged to measure the influence of surgical performance beyond baseline physiology. As baseline physiology declines, patients suffer more complications and require more therapeutic and invasive interventions. Within each physiologic risk grade, class I operations (optimal surgical performances) were associated with lower rates of morbidity, shorter hospital stays, and improved cost efficiency. Deeper analysis reveals that intraoperative blood loss is the most variable and influential factor affecting physiologic risk. Each additional unit (375 mL) of blood loss increases the odds of morbidity by 45%, prolongs hospital stay by 1 day, and costs an additional $4,000 per patient. Predictive risk assessment accurately demonstrates that escalating physiologic risk worsens postoperative morbidity, prolongs hospital duration, and increases costs after such high-acuity operations. These effects are attenuated by improved operative performance.
    Journal of the American College of Surgeons 11/2008; 207(5):717-30. · 4.50 Impact Factor
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    ABSTRACT: Epidural analgesia has emerged as a commonly applied method to improve pain management and reduce perioperative complications in major abdominal surgery. However, there is no detailed analysis of its efficacy for pancreatic operations. This study compares clinical and economic outcomes after epidural and intravenous analgesia for pancreatoduodenectomy. Data for 233 consecutive patients, who underwent pancreatoduodenectomy, were prospectively acquired and retrospectively reviewed at a single institution, pancreato-biliary specialty practice. From October 2001 to February 2007, all patients were offered thoracic epidural analgesia, and those who declined received intravenous analgesia. Perioperative pain management was dictated as an element of a standardized clinical pathway for pancreatic resections. Clinical and economic outcomes were analyzed and compared for epidural analgesia and intravenous analgesia groups. One hundred eighty-five patients received epidural analgesia, and 48 received intravenous analgesia, with equivalent baseline patient demographics between the groups. Patients administered epidural analgesia had lower pain scores but significantly higher rates of major complications. Pancreatic fistulae and postoperative ileus occurred more frequently, and patients with epidural analgesia more often required discharge to rehabilitation facilities. A trend towards longer hospitalizations was observed among epidural analgesia patients, but total costs were statistically equivalent between the groups. Further analysis demonstrates that 31% of epidural infusions were aborted before anticipated (fourth postoperative day) because of hemodynamic compromise and/or inadequate analgesia. These select patients required more transfusions, aggressive fluid resuscitation, and subsequently suffered even higher rates of gastrointestinal and respiratory complications, all attributing to higher costs. Multivariate analysis demonstrates that preoperative hematocrit concentration less than 36%, elderly age (>75 years), and chronic pancreatitis predict failure of epidural infusions. Thoracic epidural analgesia after pancreatic resections is associated with hemodynamic instability, which may compromise enteric anastomoses, gastrointestinal recovery, and respiratory function. These outcomes are exacerbated in poorly functioning epidurals and suggest that epidural analgesia may not be the optimal method for perioperative pain control when pancreatoduodenectomy is performed.
    Journal of Gastrointestinal Surgery 07/2008; 12(7):1207-20. · 2.36 Impact Factor
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    ABSTRACT: Despite significant improvements in the safety and efficacy of pancreatic surgery, post-operative pancreatic fistulae remain an unsolved dilemma. These occur when the transected pancreatic gland, pancreatic-enteric anastomosis, or both, leak rendering the patient at significant risk. They are especially important today since indications for resection (IPMN, carcinoma) continue to increase. This review considers definitions and classifications of pancreatic fistulae, risk factors, preventative approaches and offers management strategies for when they do occur. Key citations from the past seventeen years have been scrutinized, and together with personal experience, provide the basis for this review.
    Journal of Gastrointestinal Surgery 06/2008; 13(1):163-73. · 2.36 Impact Factor
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    ABSTRACT: The International Study Group on Pancreatic Fistula (ISGPF) classification scheme has become a useful system for characterizing the clinical impact of pancreatic fistula. We sought to identify predictive factors that predispose patients to fistula, specifically those with clinical relevance (grades B/C), and to describe the clinical and economic significance of risk stratification within this framework. Overall, 233 consecutive pancreatoduodenectomies were performed between October 2001 and March 2007 in our institution. Pancreatic fistula is defined according to the ISGPF classification scheme. Logistic regression analysis was performed to identify risk factors for pancreatic fistula development. These features were then analyzed to determine whether additive risk severity equates to worsening clinical and economic impact. Fistulas of any extent occurred in 60 patients, but only 31 (14%) were clinically relevant. There are no identifiable risk factors for grade A biochemical fistulas. Multivariate analysis shows that small pancreatic duct size (<3 mm); soft gland texture; ampullary, duodenal, cystic, or islet cell pathology; and increased intraoperative blood loss (>1,000 ml) are associated with clinically relevant fistulae. An additive effect is further illustrated, in which clinical and economic outcomes progressively worsen as risk profile increases. Each additional risk factor increases the odds of developing a clinically relevant fistula by 52%. For pancreatoduodenectomy, small duct size; soft gland texture; ampullary, duodenal, cystic, or islet cell pathology; and increased intraoperative blood loss are convincing risk factors for the development clinically relevant fistulae as judged by ISGPF classification. As risk profile accrues, patients suffer more complications, encounter longer hospital stays, and incur greater hospital costs. These outcomes can be predicted in the operating room through accurate delineation of high-risk glands.
    World Journal of Surgery 03/2008; 32(3):419-28. · 2.23 Impact Factor
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    ABSTRACT: The Physiologic and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) is a predictive scoring system for postoperative morbidity. While numerous studies validate its application to major abdominal surgery, few exclusively consider pancreatic resections, whose unique complications are costly and problematic. We examined whether POSSUM could accurately reflect clinical and economic outcomes in pancreatic resection. 326 consecutive pancreatic resections (227 pancreaticoduodenectomies, 87 distal, 7 central, and 5 total pancreatectomies) were performed between October 2001 and January 2007. POSSUM score was prospectively calculated for each case, and patients were stratified to quintiles of morbidity risk: < or = 20%, 20-40%, 40-60%, 60-80%, > or = 80%. Actual clinical and economic outcomes were compared across the groups. Predictive risk assessment was further evaluated independently within each resection type. Logistic regression analysis was performed to identify specific POSSUM parameters predictive of postoperative morbidity. Observed and Expected morbidity rates were equivalent (53.1% vs 55.5%) with an overall O/E ratio of 0.96. Although no patients presented with POSSUM scores below 20%, a relatively equal distribution was assigned to the remaining risk cohorts. Clinical and economic outcomes progressively worsened with escalations in POSSUM scores. Increasing morbidity risk was associated with significantly longer hospital stays, higher rates of complications, and more blood transfusions, ICU management, and discharge to rehabilitation facilities. This had considerable economic impact, as mean hospital costs rose from $19,951 in the 20-40% risk cohort, to $31,281 in the > or = 80% group. Breakdown by operation type demonstrates that POSSUM definitively predicts morbidity following both proximal and distal resection, but more accurately forecasts the need for ICU management and rehabilitation placement when pancreatoduodenectomy is performed. Multivariate analysis revealed that one-half of POSSUM parameters were significant contributors for postoperative morbidity, with age, preoperative hemoglobin concentration, and intraoperative blood loss demonstrating the strongest correlations. POSSUM is a valuable perioperative scoring system for evaluating variance in pancreatic surgical methods and outcomes, and can be employed to guide management decisions that impact postoperative recovery.
    Surgery 02/2008; 143(1):8-19. · 3.37 Impact Factor
  • Gastroenterology 01/2008; 134(4). · 12.82 Impact Factor
  • Pancreas 12/2007; 35(4):384-7. · 2.95 Impact Factor
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    ABSTRACT: The efficacy of prophylactic octreotide after pancreaticoduodenectomy has been rigorously scrutinized, yet few studies have specifically illustrated its impact in patients at high risk for pancreatic fistula. Applying a previously validated clinical classification scheme (International Study Group on Pancreatic Fistula) for postoperative pancreatic fistula severity, we examined whether prophylactic octreotide could effectuate a clinical or fiscal benefit, or both, after pancreatic resection. There were 227 consecutive patients who underwent pancreaticoduodenectomy from October 2001 to January 2007. At the surgeon's discretion, prophylactic octreotide was administered intraoperatively and continued postoperatively. Clinically relevant fistulas, requiring therapeutic interventions or resulting in severe clinical sequelae, were identified, as were other complications. Through multivariate analysis, risk factors for fistula were defined as soft gland texture; small duct size; ampullary, duodenal, cystic, or islet cell pathology; and increased blood loss. Beyond a traditional review of clinical outcomes, a novel economic cost-benefit analysis of octreotide prophylaxis was performed, with concentration of impact on high-risk glands (one or more risk factors). Overall, 55% of patients had at least one risk factor. Clinically relevant fistulas were present in 14.9% of all patients. High-risk glands resulted in significantly worse clinical and economic outcomes compared with low-risk glands (no risk factors present). Prophylactic octreotide in low-risk glands was neither clinically effective nor cost efficient after pancreaticoduodenectomy, contributing to $781 in overspending per patient--approximately equivalent to a 7-day postoperative course of octreotide. But in patients with high-risk glands, octreotide prophylaxis was associated with a decreased incidence (20% versus 35%) and morbidity of clinically relevant fistulas. These improved clinical outcomes were associated with reduced resource use, translating to considerable cost savings ($11,849) per high-risk patient. Octreotide prophylaxis is an effective approach to mitigate the negative impact of pancreatic fistulas, but to obtain maximal clinical value and cost benefit, octreotide should be administered exclusively to patients with high-risk glands.
    Journal of the American College of Surgeons 11/2007; 205(4):546-57. · 4.50 Impact Factor
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    ABSTRACT: A new quality assessment model for high-acuity surgery links process improvements with hospital costs and patient-centered outcomes and accurately reflects the clinical and economic impact of variance in patient acuity at the level of the practice and health care professional. Retrospective case series and cost analysis. University tertiary care referral center. A total of 296 patients undergoing elective pancreatic resection in 5 years. Expected preoperative morbidity (evaluated using POSSUM [Physiologic and Operative Severity Score for the Enumeration of Mortality and Morbidity]) was compared with observed morbidity (according to the Clavien complication scheme) and was correlated with total hospital costs per patient. As volume increased annually, patient acuity (expected morbidity) rose and complications declined. Overall, observed and expected morbidity rates were equal (54.1% vs 55.1%), for an observed-expected ratio of 0.98. Process improvement measures contributed to a steady decrease in the observed-expected morbidity ratio from 1.34 to 0.81 during the 5-year period. This decrease was strongly associated with significant cost savings as total costs per patient declined annually (from $31 541 to $18 829). This performance assessment model predicts that a 0.10 decrease in the observed-expected morbidity ratio equates to a $2549 cost savings per patient in our practice. Despite increasing patient acuity, better clinical and economic outcomes were achieved across time. Approaches that mitigate the impact of preoperative risk can effectively deliver quality improvement, as illustrated by a reduced observed-expected morbidity ratio. This approach is valuable in analyzing performance and process improvements and can be used to assess intrapractice and interpractice variations in high-acuity surgery.
    Archives of Surgery 05/2007; 142(4):371-80. · 4.10 Impact Factor
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    ABSTRACT: Although clinical pathways were developed to streamline patient care cost efficiently, few have been put to rigorous financial test. This is important today, because payors demand clear solutions to the cost-quality puzzle. We describe a novel, objective, and versatile model that can evaluate and link the clinical and economic impacts of clinical pathways. Outcomes for 209 consecutive patients undergoing high-acuity surgery (pancreaticoduodenectomy), before and after pathway implementation, were examined. Four grades of deviation (none to major) from the expected postoperative course were defined by merging length of stay with a validated classification scheme for complications. Deviation-based cost modeling (DBCM) links these deviations to actual total costs. Clinical outcomes compared favorably with benchmark standards for pancreaticoduodenectomy. Despite increasing patient acuity, this new pathway shortened length of stay, reduced resource use, and decreased hospital costs. DBCM indicated that fewer deviations from the expected course occurred after pathway implementation. The impacts of complications were less severe and translated to an overall cost savings of $5,542 per patient. DBCM also revealed that as more patients migrated to the expected course within our standardized care path, 50% of overall cost savings ($2,780) was attributable to the pathway alone, and improvements in care over time (secular trends) accounted for the remainder. DBCM accurately determined the incremental contribution of clinical pathway implementation to cost savings beyond that of secular trends alone. In addition, this versatile model can be customized to other systems' improvements to reveal their true clinical and economic impacts. This is valuable when choices linking quality with cost must be made.
    Journal of the American College of Surgeons 05/2007; 204(4):570-9. · 4.50 Impact Factor
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    ABSTRACT: The authors sought to validate the ISGPF classification scheme in a large cohort of patients following pancreaticoduodenectomy (PD) in a pancreaticobiliary surgical specialty unit. Definitions of postoperative pancreatic fistula vary widely, precluding accurate comparisons of surgical techniques and experiences. The ISGPF has proposed a classification scheme for pancreatic fistula based on clinical parameters; yet it has not been rigorously tested or validated. : Between October 2001 and 2005, 176 consecutive patients underwent PD with a single drain placed. Pancreatic fistula was defined by ISGPF criteria. Cases were divided into four categories: no fistula; biochemical fistula without clinical sequelae (grade A), fistula requiring any therapeutic intervention (grade B), and fistula with severe clinical sequelae (grade C). Clinical and economic outcomes were analyzed across all grades. More than two thirds of all patients had no evidence of fistula. Grade A fistulas occurred 15% of the time, grade B 12%, and grade C 3%. All measurable outcomes were equivalent between the no fistula and grade A classes. Conversely, costs, duration of stay, ICU duration, and disposition acuity progressively increased from grade A to C. Resource utilization similarly escalated by grade. Biochemical evidence of pancreatic fistula alone has no clinical consequence and does not result in increased resource utilization. Increasing fistula grades have negative clinical and economic impacts on patients and their healthcare resources. These findings validate the ISGPF classification scheme for pancreatic fistula.
    Annals of Surgery 04/2007; 245(3):443-51. · 6.33 Impact Factor

Publication Stats

486 Citations
80.38 Total Impact Points

Institutions

  • 2013
    • Hospital of the University of Pennsylvania
      Philadelphia, Pennsylvania, United States
    • University of Pennsylvania
      • Department of Surgery
      Philadelphia, PA, United States
  • 2006–2013
    • Beth Israel Deaconess Medical Center
      • Department of Surgery
      Boston, MA, United States
  • 2009
    • Harvard Medical School
      • Department of Surgery
      Boston, MA, United States