An analysis of the reduced morbidity and mortality rates after pancreaticoduodenectomy

We examined the course of 51 consecutive patients who underwent pancreaticoduodenectomies between 1979 and 1987. Fifteen patients (30%) had a traditional pancreaticoduodenectomy and 36 (70%) had a pylorus-preserving procedure. Operative blood loss, resumption of oral intake, and time to discharge from the hospital were not different for the two operations. One patient (2%) died of complications of the operation, and 14 patients (27%) had nonlethal intra-abdominal complications. Two patients required reoperation: 1 had a hemoperitoneum and 1 had a breakdown of a choledochoenterostomy. Of the patients undergoing pancreaticoduodenectomy for cancer, 26 (74%) of 35 survived 1 year, 9 (47%) of 19 survived 3 years, and 3 (33%) of 10 patients survived 5 or more years postoperatively. Our data showed that (1) on a service where a large number of these operations is performed, the mortality rate of patients who have undergone a pancreaticoduodenectomy is substantially lower than in the past and that (2) the main reasons for these improved results are greater experience of a few surgeons who perform the procedure regularly and the availability of computed tomographic scans and skilled interventional radiologists, which allows postoperative infection and pancreatic fistulas to be controlled. Although pancreaticoduodenectomy is only palliative in most patients with cancer, it provides the best palliation and the only chance of cure, and the procedure can be recommended when performed in tertiary care centers that possess these elements of success.     

Does extended pancreaticoduodenectomy increase operative morbidity and mortality vs. standard pancreaticoduodenectomy?

The poor prognosis of pancreatic carcinoma after resection is related to distant metastases and local recurrence that is characterized by a strong tendency to infiltrate the retroperitoneal tissue and spread along the neural plexuses and lymph nodes. Thorough clearance of these tissues around the celiac and mesenteric axes, aorta, and inferior vena cava from the diaphragm to the inferior mesenteric artery (extended pancreaticoduodenectomy may lower the rate of local recurrence, but the procedure has been criticized for its higher morbidity and mortality. Our aim was to compare extended pancreaticoduodenectomy (EPD) with standard pancreaticoduodenectomy (SPD) in terms of postoperative morbidity and mortality. Data from 47 patients who underwent either EPD (n=24) or SPD (n=23) between November 1992 and October 1995 were retrospectively analyzed. Preoperative laboratory findings, operative risk (according to the American Society of Anesthesiologists classification), type of operation (classic Whipple vs. pylorus-preserving Whipple), operative time, intraoperative blood and plasma transfusion, postoperative morbidity and mortality, and postoperative hospital stay were scrutinized. The results showed that all of the parameters considered were similar in the EPD and SPD groups (intraoperative blood transfusion 800±490 ml vs. 700±586 ml, postoperative mortality 0% vs. 4.3%, overall morbidity 45.8% vs. 47.8%, surgical morbidity 37.5% vs. 34.7%, and postoperative hospital stay 16±8.1 days vs 17±13.1 days. These two groups differed only in the operative time, which was significantly longer for EPD than for SPD (360±68.9 minutes vs. 330±66.9 minutes,P=0.02). Although the operative time is increased with EPD, there does not appear to be an increase in intraoperative complications, postoperative morbidity and mortality, or postoperative hospital stay with this procedure. However, definitive confirmation of these results can only be provided by a prospective randomized study. Supported in part by a grant from MURST (Italian Ministry of the University and Scientific and Technological Research), Rome Italy.     

Preoperative biliary drainage: Impact on intraoperative bile cultures and infectious morbidity and mortality after pancreaticoduodenectomy

Whether it is necessary to perform biliary drainage for obstructive jaundice before performing pancreaticoduodenectomy remains controversial. Our aim was to determine the impact of preoperative biliary drainage on intraoperative bile cultures and postoperative infectious morbidity and mortality following pancreaticoduodenectomy. We retrospectively analyzed 161 consecutive patients undergoing pancreaticoduodenectomy in whom intraoperative bile cultures were performed. Microorganisms were isolated from 58% of these intraoperative bile cultures, with 70% of them being polymicrobial. Postoperative morbidity was 47% and mortality was 5%. Postoperative infectious complications occurred in 29%, most commonly wound infection (14%) and intra-abdominal abscess (12%). Eighty-nine percent of patients with intra-abdominal abscess (P = 0.003) and 87% with wound infection (P = 0.003) had positive intraoperative bile cultures. Microorganisms in the bile were predictive of microorganisms in intraabdominal abscess (100%) and wound infection (69%). Multivariatc analysis of preoperative and intraoperative variables demonstrated that preoperative biliary drainage was associated with positive intraoperative bile cultures (P <0.001), postoperative infectious complications (P = 0.022), intra-abdominal abscess (P = 0.061), wound infection (P = 0.045), and death (P = 0.021). Preoperative biliary drainage increases the risk of positive intraoperative bile cultures, postoperative infectious morbidity, and death. Positive intraoperative bile cultures are associated with postoperative infectious complications and have similar microorganism profiles. These data suggest that preoperative biliary drainage should be avoided in candidates for pancreaticoduodenectomy. Presented at the 1998 Annual Meeting of the American Gastroenterological Association, New Orleans, La., May 19, 1998.     

胰十二指肠切除术严重并发症和病死率的多因素分析

目的探讨胰十二指肠切除术的术后严重并发症及其危险因素。方法回顾性分析1987年1月至2006年8月郑州大学第五附属医院138例行胰十二指肠切除术病人的手术死亡和术后严重并发症的情况,并通过单因素分析和多因素分析评价其危险因素。结果住院期间病人病死率为13.0%(18/138),与手术相关的严重并发症发生率为41.3%(57/138)。Logistic回归分析显示,发生并发症危险因素依次是术前总胆红素升高、低蛋白血症、高血压、年龄和术中出血量多。结论低蛋白血症和术前总胆红素升高是胰十二指肠切除术术后并发症最主要的危险因素,手术者掌握好手术适应证、积极纠正或削弱危险因素,能有效降低术后并发症的发生。     

Decreased morbidity and mortality after pancreatoduodenectomy

In two 5 year periods (1975 to 1979 and 1980 to 1984), 96 patients underwent pancreatoduodenal resection, which included 74 partial pancreatic resections and 22 total pancreatectomies. Thirty-seven of these patients had resections with preservation of the pylorus. Substantial reductions in perioperative mortality (2 percent versus 10 percent) and morbidity (26 percent versus 49 percent) (p less than 0.05) were achieved in the latter period. Pylorus preservation, with a mortality and morbidity of 3 percent and 27 percent, respectively, did not increase operative risk or compromise long-term survival in patients with malignant disease. In comparison, relatively high mortality and morbidity rates (14 percent and 59 percent) accompanied total pancreatectomy without improved long-term survival. Five year actuarial survival for nonpancreatic periampullary adenocarcinomas was 58 percent. Thus, we recommend pancreatoduodenectomy with preservation of the pylorus for resection of periampullary tumors. These patients, whose only possibility for cure is a major pancreatic resection, should not be denied this opportunity on the basis of reports from a previous era.     

Cardiac mortality and morbidity after vascular surgery

To determine the clinical, hemodynamic and pathological features that contribute to major cardiac complications after vascular surgery, six patients with early postoperative cardiogenic shock (group 1) were analysed retrospectively and compared to nine patients without complications (group 2) who were carefully analysed prospectively. Four group 1 patients had elective repair of an abdominal aortic aneurysm, one had repair of a false iliac artery aneurysm and one had a femoropopliteal graft inserted. Four group 2 patients had elective repair of an abdominal aortic aneurysm and five had aortobifemoral reconstruction. The Goldman multifactorial index was similar in both groups and indicated an expected death rate of 2% and a morbidity rate of 5%. In group 1, the earliest sign of cardiovascular compromise was an elevated pulmonary wedge pressure during operation. Postoperatively, electrocardiographic evidence of myocardial ischemia was present in all six patients and preceded cardiogenic shock. Autopsy of the four patients who died demonstrated triple-vessel disease in all but recent occlusion in only one patient. There was evidence of extensive subendocardial infarction in all four. Angiography of the two survivors in group 1 also demonstrated triple-vessel disease. The authors conclude that by using ordinary clinical methods it is difficult to identify patients likely to have major complications postoperatively. Elevated pulmonary wedge pressures or electrocardiographic evidence of myocardial ischemia may be early warning signs of impending cardiac catastrophe and should be treated aggressively. The underlying pathophysiology appears to be perioperative stress in a setting of severe triple-vessel coronary artery disease.     

Cardiovascular morbidity and mortality after kidney transplantation

Kidney transplantation is the optimal treatment for patients with end stage renal disease (ESRD) who would otherwise require dialysis. Patients with ESRD are at dramatically increased cardiovascular (CV) risk compared with the general population. As well as improving quality of life, successful transplantation accords major benefits by reducing CV risk in these patients. Worldwide, cardiovascular disease remains the leading cause of death with a functioning graft and therefore is a leading cause of graft failure. This review focuses on the mechanisms underpinning excess CV morbidity and mortality and current evidence for improving CV risk in kidney transplant recipients. Conventional CV risk factors such as hypertension, diabetes mellitus, dyslipidaemia and pre‐existing ischaemic heart disease are all highly prevalent in this group. In addition, kidney transplant recipients exhibit a number of risk factors associated with pre‐existing renal disease. Furthermore, complications specific to transplantation may ensue including reduced graft function, side effects of immunosuppression and post‐transplantation diabetes mellitus. Strategies to improve CV outcomes post‐transplantation may include pharmacological intervention including lipid‐lowering or antihypertensive therapy, optimization of graft function, lifestyle intervention and personalizing immunosuppression to the individual patients risk profile.     

Use of the pre-operative shuttle walk test to predict morbidity and mortality after elective major colorectal surgery

High-risk surgery is performed in every acute hospital. These patients often have increased peri-operative risk related to their poor cardiorespiratory reserve. Formal risk assessment is recommended for such patients; cardiopulmonary exercise testing is a well established triage tool, but is unavailable in many hospitals. We investigated whether a simple exercise test could predict postoperative outcome using a prospective trial of 121 patients undergoing elective major abdominal surgery. Each patient completed a shuttle walk test and was followed up for 30 days after surgery. There was one postoperative death (0.8%), with 53 patients (44%) developing complications. The mean (SD) shuttle walk test distance was significantly different between patients who suffered complications and those who did not (276.6 (134.5) vs 389.6 (138.9) m, respectively; p < 0.001). A cut-off distance of 250 m had a specificity of 0.88 and a sensitivity of 0.58 to predict postoperative complications. Patients unable to complete a shuttle walk test above this cut-off distance were three times more likely to have a postoperative morbidity. We conclude that the shuttle walk test can help identify patients who are at increased peri-operative risk.     

Changes in albuminuria predict mortality and morbidity in patients with vascular disease

The degree of albuminuria predicts cardiovascular and renal outcomes, but it is not known whether changes in albuminuria also predict similar outcomes. In two multicenter, multinational, prospective observational studies, a central laboratory measured albuminuria in 23,480 patients with vascular disease or high-risk diabetes. We quantified the association between a greater than or equal to twofold change in albuminuria in spot urine from baseline to 2 years and the incidence of cardiovascular and renal outcomes and all-cause mortality during the subsequent 32 months. A greater than or equal to twofold increase in albuminuria from baseline to 2 years, observed in 28%, associated with nearly 50% higher mortality (HR 1.48; 95% CI 1.32 to 1.66), and a greater than or equal to twofold decrease in albuminuria, observed in 21%, associated with 15% lower mortality (HR 0.85; 95% CI 0.74 to 0.98) compared with those with lesser changes in albuminuria, after adjustment for baseline albuminuria, BP, and other potential confounders. Increases in albuminuria also significantly associated with cardiovascular death, composite cardiovascular outcomes (cardiovascular death, myocardial infarction, stroke, and hospitalization for heart failure), and renal outcomes including dialysis or doubling of serum creatinine (adjusted HR 1.40; 95% CI 1.11 to 1.78). In conclusion, in patients with vascular disease, changes in albuminuria predict mortality and cardiovascular and renal outcomes, independent of baseline albuminuria. This suggests that monitoring albuminuria is a useful strategy to help predict cardiovascular risk.     

Postoperative morbidity and long-term survival after pancreaticoduodenectomy with superior mesenterico-portal vein resection

The role of superior mesenteric-portal vein resection (SM-PVR) for vein invasion or tumor adherence during pancreatoduodenectomy (PD) is still under debate. We investigated morbidity, mortality, and long-term survival in patients who underwent PD with or without SM-PVR. Between July 1994 and December 2004, 222 PD (78% pylorus preserving, 19% Whipple, and 3% total pancreatectomy) were performed for malignant disease. Fifty-three patients (24%) had PD with SM-PVR. Sixty-eight percent of the venous resections were performed as wedge excisions and 32% as segmental resections. Long-term survival was analyzed in 165 patients with pancreatic (n=110), ampullary (n=33), or distal bile (n=22) duct cancer using univariate (log-rank) and multivariate (Cox regression) methods. In patients undergoing PD with SM-PVR and conclusive histologic examination of the resected vein specimen (n=42), 60% had true tumor involvement of the venous wall, whereas 40% had no proven tumor infiltration. In the complete study group, negative resection margins were obtained in 69% of patients with SM-PVR and in 79% of patients without SM-PVR (P=0.09). Median duration of surgery was 500 minutes (SM-PVR) versus 440 minutes (no SM-PVR; P<0.001). Volume of intraoperatively transfused blood was 600 ml (median) in both groups. Postoperative surgical complications/mortality occurred in 23%/3.8% (SM-PVR) versus 35%/4.1% (no SM-PVR); P=0.09/0.9. Analysis of long-term survival in all 165 patients included 41 with SM-PVR. Five-year survival rates were 15% in cancer of the pancreatic head, 22% in ampullary cancer, and 24% in distal bile duct cancer (P=0.02). Long-term survival was not influenced by the need for SM-PVR in any of the different tumor entities. In multivariate analysis, a positive resection margin (P<0.01, relative risk [RR]: 1.8, 95% confidence interval [CI]: 1.2–2.7), a histologically undifferentiated tumor (P=0.01, RR: 1.7, 95% CI: 1.1–2.5), and the tumor entity (P<0.01) were significant predictors of survival. Univariate survival analysis of the 110 patients with cancer of the pancreatic head revealed that a histologically undifferentiated tumor (P=0.05) and positive resection margins (P=0.02) were associated with a poorer survival. In multivariate analysis, the resection margin (P=0.02, RR: 5.1, 95% CI: 1.1–2.8) and a histologically undifferentiated tumor (P=0.05, RR: 3.8, 95% CI: 1.0–2.5) significantly influenced survival. After PD, perioperative morbidity and long-term survival in patients with SM-PVR were similar to those of patients without vein resection. In case of tumor adherence or infiltration, combined resection of the pancreatic head and the vein should always be considered in the absence of other contraindications for resection. Initial results were presented at the Forty-Fourth Annual Meeting of The Society for Surgery of the Alimentary Tract, Orlando, Florida, May 18–21, 2003 (poster).     

Cardiovascular morbidity and mortality after orthotopic liver transplantation

BACKGROUND: Hyperlipidemia and hypertension have been reported in liver allograft recipients and contribute to an increased risk of ischemic heart disease (IHD) after orthotopic liver transplantation (OLT). The aims of the study were (1) to determine the prevalence of risk factors for IHD in these patients and (2) to compare the observed incidence of cardiovascular events and related mortality in allograft recipients with a matched population. METHODS: One hundred ten consecutive adults (50 male) who attended for review after OLT (median follow-up 3.9 years; range 0.1-17.9) were assessed for cardiovascular risk factors using current blood pressure, diabetic status, and smoking history and measurements of total cholesterol, high-density lipoprotein cholesterol, and triglyceride concentrations. Cardiovascular events and cardiovascular mortality data were collected from the prospective database of all adult liver allograft recipients and compared to matched data from myocardial infarction registries and Office for National Statistics data, respectively. RESULTS: Raised serum cholesterol (>5.0 mmol/L) was found in 48 (44%) patients (18 male), and systolic hypertension (>140 mmHg) was found in 69 (63%) patients (27 male). The relative risk of ischemic cardiac events was 3.07 (95% [confidence interval] CI, 1.98-4.53) and the relative risk for cardiovascular deaths was 2.56 (95% CI, 1.52-4.05) in allograft recipients compared to an age-matched population without transplants. CONCLUSIONS: Liver allograft recipients have a greater risk of cardiovascular deaths and ischemic events than an age- and sex-matched population. The prevalence of raised cholesterol concentrations in patients after OLT is similar to those in previous reports. Moderate hypertension and hyperlipidemia may be more detrimental in patients after OLT compared to non-transplant patients without these risk factors.     

Determinants of perioperative morbidity and mortality after pneumonectomy

A total of 197 consecutive patients undergoing pneumonectomy at the M.D. Anderson Cancer Center from 1982 to 1987 were reviewed. Sixty-five variables were analyzed for the predictive value for perioperative risk. The operative mortality rate was 7% (14/197). Patients having a right pneumonectomy (n = 95) had a higher operative mortality rate (12%) than patients having a left pneumonectomy (1%, p less than 0.05). The extent of resection correlated with the operative mortality rate (chest wall resection or extrapleural pneumonectomy, n = 39, 15%; versus simple or intrapericardial pneumonectomy, n = 158, 5%; p less than 0.05). Patients whose predicted postoperative pulmonary function, by spirometry and xenon 133 regional pulmonary function studies, was a forced expiratory volume in 1 second greater than 1.65 L, forced expiratory volume in 1 second greater than 58% of the preoperative value, forced vital capacity greater than 2.5 L, or forced vital capacity greater than 60% of the preoperative value had a lower operative mortality rate (p less than 0.05). Atrial arrhythmia was the most common postoperative complication (23%). Xenon 133 regional pulmonary function studies are useful in predicting the risks of pneumonectomy.     

Real surgical morbidity and mortality after extrapleural pneumonectomy

As for other major thoracic operations the conventional 30-day morbidity and mortality marker may underestimate the actual surgical risk of extrapleural pneumonectomy. We retrospectively analysed the prolonged follow-up of 78 patients submitted to extrapleural pneumonectomy for pleural mesothelioma (55), lung cancer with associated carcinomatous (7) or purulent (8) pleuritis, empyema/destroyed lung (4), and mediastinal (2) and chest wall (2) tumours with pleuro-pulmonary involvement. Significant rates of surgery-related major complications (19%) and fatalities (6.6%) additionally occurred beyond 30 days and within 6 months of extrapleural pneumonectomy, making a 66% cumulative (early + late) morbidity rate and an 11.5% cumulative mortality rate, which are respectively 50% and 100% greater than the 30-day rate alone. The leading causes of late morbidity and mortality were respiratory/cardiac sequelae (50%) and broncho-pleural fistulas (30%). Strict preoperative functional selection and proper application of the technical learning curve can reduce the occurrence of the adverse events by anything up to 50% (early mortality: 2.3%). If the results of this novel study of long-term surgical outcomes of extrapleural pneumonectomy were to be confirmed, the preoperative risk/benefit balance of the procedure, mainly when performed for thoracic malignancies, should therefore include the entire spectrum of (early and late) potential surgery-related complications.