Rescue from complications after pancreaticoduodenectomies at a low-volume Caribbean center: Value of tailored peri-pancreatectomy protocols

Shamir O Cawich; Elijah Dixon; Parul J Shukla; Shailesh V Shrikhande; Rahul R Deshpande; Fawwaz Mohammed; Neil W Pearce; Wesley Francis; Shaneeta Johnson; Johann Bujhawan

doi:10.4240/wjgs.v16.i3.681

Rescue from complications after pancreaticoduodenectomies at a low-volume Caribbean center: Value of tailored peri-pancreatectomy protocols

World J Gastrointest Surg. 2024 Mar 27;16(3):681-688. doi: 10.4240/wjgs.v16.i3.681.

Authors

Affiliations

¹ Department of Surgery, University of the West Indies, St Augustine 000000, Trinidad and Tobago. socawich@hotmail.com.
² Department of Surgery, Faculty of Medicine, University of Calgary, Calgary, Alberta T2N2T9, Canada.
³ Department of Surgery, Weill Cornell Medical College, New York, NY 10065, United States.
⁴ Department of Surgical Oncology, Tata Memorial Center, Homi Bhabha National University, Mumbai 400012, India.
⁵ Department of Surgery, Manchester Royal Infirmary, Manchester M13 9WL, United Kingdom.
⁶ Department of Surgery, University of the West Indies, St Augustine 000000, Trinidad and Tobago.
⁷ University Surgical Unit, Southampton General Hospital, Southampton SO16 6YD, United Kingdom.
⁸ Department of Surgery, University of the West Indies, Nassau N-1184, Bahamas.
⁹ Department of Surgery, Morehouse School of Medicine, Atlanta, GA 30310, United States.
¹⁰ Department of Surgery, General Hospital in Port of Spain, Port of Spain 000000, Trinidad and Tobago.

Abstract

Background: Pancreaticoduodenectomy (PD) is a technically complex operation, with a relatively high risk for complications. The ability to rescue patients from post-PD complications is as a recognized quality measure. Tailored protocols were instituted at our low volume facility in the year 2013.

Aim: To document the rate of rescue from post-PD complications with tailored protocols in place as a measure of quality.

Methods: A retrospective audit was performed to collect data from patients who experienced major post-PD complications at a low volume pancreatic surgery unit in Trinidad and Tobago between January 1, 2013 and June 30, 2023. Standardized definitions from the International Study Group of Pancreatic Surgery were used to define post-PD complications, and the modified Clavien-Dindo classification was used to classify post-PD complications.

Results: Over the study period, 113 patients at a mean age of 57.5 years (standard deviation [SD] ± 9.23; range: 30-90; median: 56) underwent PDs at this facility. Major complications were recorded in 33 (29.2%) patients at a mean age of 53.8 years (SD: ± 7.9). Twenty-nine (87.9%) patients who experienced major morbidity were salvaged after aggressive treatment of their complication. Four (3.5%) died from bleeding pseudoaneurysm (1), septic shock secondary to a bile leak (1), anastomotic leak (1), and myocardial infarction (1). There was a significantly greater salvage rate in patients with American Society of Anesthesiologists scores ≤ 2 (93.3% vs 25%; P = 0.0024).

Conclusion: This paper adds to the growing body of evidence that volume alone should not be used as a marker of quality for patients requiring PD. Despite low volumes at our facility, we demonstrated that 87.9% of patients were rescued from major complications. We attributed this to several factors including development of rescue protocols, the competence of the pancreatic surgery teams and continuous, and adaptive learning by the entire institution, culminating in the development of tailored peri-pancreatectomy protocols.

Keywords: Complication; Failure; Morbidity; Mortality; Pancreas; Pancreaticoduodenectomy; Rescue.