Reduction of alkaline reflux gastritis and marginal ulcer by modified Braun enteroenterostomy in gastroenterologic reconstruction after pancreaticoduodenectomy

Background

The incidence of alkaline reflux gastritis (ARG) after pancreaticoduodenectomy (PD) is high. Although Braun enteroenterostomy (BEE) may reduce ARG, BEE may result in marginal ulcers (MUs) due to the additional anastomotic stoma. We conducted this study to compare clinical outcomes of using a modified BEE (MBEE) with traditional gastrojejunostomy (TGJ), by inducting a purse-string suture instead of an additional anastomotic stoma.

Materials and methods

All 62 patients underwent standard PD at the Department of Hepatobiliopancreatic Surgery of West China Hospital between January 1, 2008 and January 31, 2012. Demographics, perioperative and postoperative factors, and follow-up morbidity were compared in those patients who underwent MBEE (n = 32, three patients were lost to follow-up) to those who underwent TGJ (n = 30, nine patients were lost to follow-up).

Results

Patients who underwent the MBEE experienced a decrease in total morbidity including ARG and MUs, relative to those who underwent TGJ (24.1% versus 58.3%, P = 0.011). With regard to the MBEE group, the total ARG rate was statistically significantly lower compared with the TGJ group (13.8% versus 37.5%, P = 0.046). In addition, the incidence of MUs was reduced.

Conclusions

In patients undergoing PD, the MBEE was safely performed with significantly more patients having reduced incidence of ARG and related sequela compared with those who underwent TGJ. These results support further study of patients undergoing gastroenterostomy after resection of the distal stomach in larger, randomized studies.     

Can surgical performance benchmarking be generalized across multiple outcomes databases: a comparison of University HealthSystem Consortium and National Surgical Quality Improvement Program

Background

Surgeon's performance is tracked using patient outcomes databases. We compared data on patients undergoing laparoscopic cholecystectomy from 2 large databases with significant institutional overlap to see if either patient characteristics or outcomes were similar enough to accurately compare performance.

Methods

Data from 2009 to 2011 were collected from University HealthSystem Consortium (UHC) and National Surgical Quality Improvement Program (NSQIP). UHC and NSQIP collect data from over 200 and 400 medical centers, respectively, with an overlap of 70. Patient demographics, pre-existing medical conditions, operative details, and outcomes were compared.

Results

Fifty-six thousand one hundred ninety-seven UHC patients and 56,197 NSQIP patients met criteria. Groups were matched by age, sex, and pre-existing comorbidities. Outcomes for NSQIP and UHC differed, including mortality (.20% NSQIP vs .12% UHC; P < .0001), morbidity (2.0% vs 1.5%; P < .0001), wound infection (.07% vs .33%; P < .0001), pneumonia (.38% vs .75%; P < .0001), urinary tract infections (.62% vs .01%; P < .0001), and length of hospital stay (1.8 ± 7.5 vs 3.8 ± 3.7 days; P = .0004), respectively.

Conclusions

Surgical outcomes are significantly different between databases and resulting performance data may be significantly biased. A single unified national database may be required to correct this problem.     

Pylorus resection in partial pancreaticoduodenectomy: impact on delayed gastric emptying

Background

Partial pancreaticoduodenectomy (PD) is complicated by postoperative delayed gastric emptying (DGE) in up to 45% of patients. The aim of this study was to evaluate the impact of pylorus resection on DGE following PD.

Methods

Forty PD patients underwent pylorus resection with complete stomach preservation (prPD). They were compared with a pair-matched group of PD patients with pylorus preservation (ppPD) in a 1:1 ratio (age, sex, histopathology). The objectives were operative parameters, DGE incidence, morbidity, and length of hospital stay.

Results

DGE incidence was significantly lower after prPD (15.0% vs 42.5%; P = .0066). Operative parameters and surgical morbidity (other than DGE) were not different (27.5% prPD vs 30.0% ppPD). There was a trend toward a shorter hospital stay in the prPD group.

Conclusions

Resection of the pylorus with stomach preservation significantly reduces the frequency of DGE after PD without showing any disadvantage when compared with standard ppPD. This finding could be of high relevance for the clinical practice in routine PD and should consequently be investigated in a large randomized multicenter trial to create further evidence.     

Does an aberrant right hepatic artery really influence the short- and long-term results of a pancreaticoduodenectomy for malignant disease? A matched case-controlled study

Background

An aberrant right hepatic artery (ARHA) is a common anatomic variation. The risk associated with ARHA during pancreaticoduodenectomy (PD) continues to be debated. The aim of this study was to compare the clinical outcomes and survival after PD with ARHA against a matched cohort of patients without ARHA.

Methods

PD with an ARHA performed between January 2000 and September 2009 were retrospectively analyzed. Patients with an ARHA (group 1) were matched (1:2) to patients without an ARHA (group 2) according to gender, age, body mass index, type of tumor, and lymph node status. Peri- and postoperative outcomes were compared between the two groups. Overall survival and disease-free survival were estimated by Kaplan-Meier method and compared with log-rank test.

Results

A total of 29 patients (group 1) and 55 patients (group 2) were compared. In group 1, an ARHA entered the tumor in six cases (20.7%), was sacrificed in four cases, and repaired in two cases. There was no difference regarding the rate of intraoperative and postoperative variables between the two groups. The oncological clearance (P = 0.731) and survival (overall survival, P = 0.843; disease-free survival, P = 0.832) were also similar.

Conclusions

Our study showed that the presence of an ARHA during PD was not associated with worse postoperative outcomes or survival.     

Braun enteroenterostomy during pancreaticoduodenectomy decreases postoperative delayed gastric emptying

Background

Modified digestive reconstruction during pancreaticoduodenectomy (PD) may affect the postoperative incidence of delayed gastric emptying (DGE). The purpose of this study is to investigate whether Braun enteroenterostomy following PD can reduce the incidence of DGE.

Methods

Four hundred seven patients who received PD with child reconstruction from June 2000 to March 2013 were divided into 2 groups: 206 patients with Braun enteroenterostomy (Child-Braun group) and 201 patients without Braun enteroenterostomy (Child-non-Braun group). Clinical data were retrospectively extracted; univariate and multivariate analyses were performed to investigate the association between Braun enteroenterostomy and DGE.

Results

DGE was less frequent in the Child-Braun group than in the Child-non-Braun group (6.7% vs 26.87%, P < .001). The multivariate logistic regression analysis showed that Braun enteroenterostomy was the only significant independent factor associated with the reduced DGE after PD with Child reconstruction, with an odds ratio of 4.485 (95% confidence interval: 2.372 to 8.482, P < .001).

Conclusion

Braun enteroenterostomy reduces the incidence of postoperative DGE associated with PD.     

Impact of a blood conservation program on 30-day morbidity and mortality: a cohort study

Background

There are little published data on outcomes of blood conservation (BC) patients after noncardiac surgery. The objective of this study was to compare the surgical outcomes of patients enrolled in our BC program with that of the general population of surgical patients.

Methods

BC patients at our institution undergoing various surgical procedures were identified from the 2007–2009 National Surgical Quality Improvement Program database and compared with a cohort of conventional care (CC) patients matched by age, gender, and surgical procedure. Univariate and multiple logistic regression analyses were performed to evaluate 30-d postoperative outcomes.

Results

One hundred twenty BC patients were compared with 238 CC patients. The two groups were similar for all preoperative variables except smoking, which was lower in the BC group. On univariate analysis, BC patients had similar mean operating time (148 versus 155 min; P = 0.5), length of stay (5.9 versus 5.5 d; P = 0.7), and rate of return to the operating room (7.5% versus 5.5%; P = 0.4) compared with CC patients. BC and CC patients had similar 30-d morbidity (18% versus 14%; P = 0.3) and mortality rates (1.6% versus 1.3%; P = 1.0), respectively. On multivariable analysis, enrollment in the BC program had no impact on postoperative 30-d morbidity (odds ratio, 1.78; 95% confidence interval, 0.71–4.47) or 30-d mortality (unadjusted odds ratio, 1.33; 95% confidence interval, 0.22–8.05).

Conclusions

Short-term postoperative outcomes in BC patients are similar to the general population, and these patients should not be denied surgical treatment based on their unwillingness to receive blood products.     

Esophagectomy in patients with prior percutaneous endoscopic gastrostomy tube placement

Background

The impact of preoperative percutaneous endoscopic gastrostomy (PEG) tube placement in patients undergoing esophagectomy is uncertain.

Methods

A retrospective review was performed in consecutive patients who underwent esophagectomy. Patients were divided into groups based on whether or not they had preoperative PEG placement.

Results

One hundred seventeen patients were studied, 102 without (PEG−) and 15 with PEG+ before PEG tube placement. The overall morbidity and mortality rates were 38% and 3%, respectively. The use of a gastric conduit was similar between groups (94% PEG− vs 87% PEG+, P = .27), and the presence of a PEG before PEG tube placement was not prohibitive in any case. Anastomotic leak rates were similar between groups (11% PEG− vs 15% PEG+, P = .65), and there were no leaks from previous PEG sites.

Conclusion

It appears that preoperative PEG tube placement has no adverse effect on the performance of esophagectomy and may be considered in highly selected patients with poor nutritional status.     

Disparities in trauma: the impact of socioeconomic factors on outcomes following traumatic hollow viscus injury

Background

This piece aims to examine the relationships between hollow viscus injury (HVI) and socioeconomic factors in determining outcomes. HVI has well-defined injury patterns with complex postoperative convalescence and morbidity, representing an ideal focus for identifying potential disparities among a homogeneous injury population.

Materials and methods

A retrospective review included patients admitted to a level I trauma center with HVI from 2000–2009, as identified in the Trauma Registry of the American College of Surgeons. Patients with concomitant significant solid organ or vasculature injury were excluded. US Census (2000) median household income by zip code was used as socioeconomic proxy. Demographic and injury-related variables were also included. Endpoints were mortality and outcomes associated with HVI morbidity.

Results

A total of 933 patients with HVI were identified and 256 met inclusion criteria. There were 23 deaths (9.0%), and mortality was not associated with race, gender, income, or payer source. However, lower median household income was significantly associated with longer intervals to ostomy takedown (P = 0.032). Additionally, private payers had significantly lower rates of anastomotic leak (0% [0/73] versus 7.1% [13/183], P = 0.019) and fascial dehiscence (5.5% [4/73] versus 16.9% [31/183], P = 0.016), while self-payers had significantly higher rates of abscess formation, both overall (24% [24/100] versus 10.2% [16/156], P = 0.004) and among penetrating injuries (27.4% [23/84] versus 13.6% [12/88], P = 0.036).

Conclusions

Socioeconomic status may not impact overall mortality among trauma patients with hollow viscus injuries, but private insurance appears to be protective of morbidity related to anastomotic leak, fascial dehiscence, and abscess formation. This supports that socioeconomic disparity may exist within long-term outcomes, particularly regarding payer source.     

Preoperative cholangitis during biliary drainage increases the incidence of postoperative severe complications after pancreaticoduodenectomy

Background

It remains controversial how preoperative biliary drainage affects occurrence of severe complications after pancreaticoduodenectomy (PD).

Methods

One hundred twenty-seven patients (60 external drainage and 67 internal drainage) required biliary drainage before PD were retrospectively reviewed.

Results

Preoperative cholangitis in internal drainage group (22.4%) occurred significantly more often than in external drainage group (1.7%; P < .001). The incidence of severe complications (grade III or more) was significantly higher in patients with cholangitis (62.5%) than in those without it (25.2%; P = .002). The incidence of delayed gastric emptying was significantly higher in patients with cholangitis (31.2%) than in those without it (5.4%; P = .001). A multivariate logistic regression analysis revealed that preoperative cholangitis (odds ratio 4.61, 95% confidence interval 1.3 to 16.5; P = .019) was the independent risk factor for severe complications after PD.

Conclusions

Preoperative cholangitis during biliary drainage significantly increases incidence of severe complications after PD.     

Pilonidal disease in a military population: how far have we really come?

Background

Pilonidal disease (PD) has a long connection with military personnel, even nicknamed “jeep disease” during World War II. The aim of this study was to identify factors associated with recurrence and complications after surgery in a military population.

Methods

A retrospective cohort analysis of operative therapy for PD at a single institution from 2005 to 2011 was conducted. Patient demographics, disease characteristics, and surgical methods were assessed for the primary outcomes of recurrence and morbidity.

Results

A total of 151 patients with PD were identified, who underwent excision (45.7%), excision with primary closure (29.8%), and incision and drainage (9.9%). Overall recurrence and morbidity rates were 27.2% and 34.4%, respectively. Black race, chronic disease, wound infection, and infection and drainage were associated with recurrence (P < .05), and excision with primary closure was associated with increased complications (P < .001).

Conclusions

PD remains a significant source of morbidity and recurrence among military personnel. Certain patient-related and disease-related factors portend a worse prognosis, with black race and operative method the strongest predictors of outcomes.     

Comparison of surgical outcomes between papillary thyroid cancer patients treated with the Harmonic ACE scalpel and LigaSure Precise instrument during conventional thyroidectomy: a single-blind prospective randomized controlled trial

Background

The aim of this study was to evaluate the safety and efficacy of thyroidectomy using the Harmonic ACE scalpel (HS) or the LigaSure Precise (LS) instrument in conventional thyroidectomy.

Materials and methods

A prospective, randomized controlled trial was performed. Between August 2011 and June 2012, 832 patients who required thyroidectomy for papillary thyroid cancer were randomized into groups treated with either the HS or the LS instrument. Operative time and surgical morbidities were analyzed.

Results

A total of 320 patients (HS group, N = 164; LS instrument group, N = 156) were randomized for analysis according to the intention-to-treat principle. There were no statistically significant differences in the operative times (HS group versus LS instrument group: 71.93 ± 18.26 versus 75.15 ± 20.13; P = 0.423), postoperative transient hypoparathyroidism (13.4% versus 14.1%; P = 0.858), and permanent recurrent laryngeal nerve injuries between the two groups.

Conclusions

In this study, both hemostatic devices were safe and effective in terms of postoperative results and complications without any differences.     

Accuracy of American College of Surgeons National Surgical Quality Improvement Program Pediatric for laparoscopic appendectomy at a single institution

Background

In October 2008, the American College of Surgeons revealed the National Surgical Quality Improvement Program (NSQIP) Pediatric in an effort to improve quality of surgical care in children. A 5% disagreement rate of data reported between institutions is accepted. The two goals of this study were to (1) determine if the random sampling performed with NSQIP data collection was representative of the population, and (2) verify that data captured in NSQIP was accurate.

Methods

For children undergoing laparoscopic appendectomy from April 2010–April 2011, demographic data, length of stay (LOS), and rates of surgical site infection (SSI) and postoperative abscess recorded in NSQIP (group 1) were compared with data from chart review (group 2). Secondarily, all NSQIP data were examined for accuracy by comparing relevant data points to existing databases. All disagreements were further examined with review of the medical chart. Unpaired t-test and χ² with Fisher's exact test were used in the statistical analysis.

Results

NSQIP Pediatric captured data from 126 children (group 1); group 2 had 525 children. There were no significant differences in age, body mass index, gender, race or LOS between the two groups. Rate of SSI was 1.6% in group 1 and 1.7% in group 2 (P = 0.92). Abscess rate was 1.6% in group 1 and 3.4% in group 2 (P = 0.28). There were six errors in the NSQIP database. One child was listed as having two SSI. One child with postoperative abscess was missed and another was not counted as they were not categorized correctly. Recorded LOS was incorrect for two children and the other had incorrect age.

Conclusions

NSQIP Pediatric captured a representative sample of patients undergoing laparoscopic appendectomy. Errors were found in the reporting of outcomes for SSI and postoperative abscess in children undergoing laparoscopic appendectomy. Given the low incidence of these outcomes, there is little effect on percentages of complications reported.     

Hernia repair in the presence of ascites

Background

The model for end-stage liver disease (MELD) has been validated as a prediction tool for postoperative mortality, but its role in predicting morbidity has not been well studied. We sought to determine the role of MELD, among other factors, in predicting morbidity and mortality in patients with nonmalignant ascites undergoing hernia repair.

Methods

All patients undergoing hernia repair in the American College of Surgeons National Surgical Quality Improvement database (2009–11) were identified. Those with nonmalignant ascites were compared with patients without ascites. A subset analysis of patients with nonmalignant ascites was performed to evaluate the association between MELD and morbidity and mortality with adjustment for potential confounders. The association of significant factors with the rate of morbidity was displayed using a best-fit polynomial regression.

Results

Of 138,366 hernia repairs, 778 (0.56%) were performed on patients with nonmalignant ascites. Thirty-day morbidity (4% versus 19%) and mortality (0.2% versus 5.3%) were significantly more frequent in patients with ascites (P < 0.001). In univariate analysis of the 636 patients with a calculable MELD, MELD was associated with both morbidity and mortality (P < 0.001 each). In multivariate analysis, MELD remained significantly associated with morbidity (odds ratio [OR] = 1.11). Ventral hernia repair (OR = 2.9), dependent functional status (OR = 2.3), alcohol use (OR = 2.3), emergent operation (OR = 2.0) white blood count (OR = 1.1), and age (OR = 1.02) were also significantly associated with morbidity (P < 0.05).

Conclusions

Before hernia repair, the MELD score can be used to risk-stratify patients with nonmalignant ascites not only for mortality but also morbidity. Morbidity rates increase rapidly with MELD above 15, but other factors should additionally be accounted for when counseling patients on their perioperative risk.     

A 2-wk conservative treatment regimen preceding thoracic duct ligation is effective and safe for treating post-esophagectomy chylothorax

Background

Chylothorax is a pathologic condition defined by an accumulation of lymphatic fluid, the chyle, in the thorax. Postoperative chylothorax is a potentially lethal complication, with a reported mortality rate of 15.4%–25%.

Patients and methods

Esophageal cancer patients hospitalized for elective radical esophagectomy by thoracotomy (n = 10,574) were consecutively enrolled between January 1996 and December 2011. Patients (n = 306) who experienced post-esophagectomy chylothorax were assigned to a 48-h (group A, n = 186) or to a 2-wk (group B, n = 120) conservative treatment regimen. For patients with a daily chylothorax output >1000 mL, thoracic duct ligation (TDL) was performed by thoracotomy. Measured outcomes included frequency of TDL, overall and treatment-specific morbidity and mortality rates, and the rate of chylothorax recurrence.

Results

A total of 171 patients (171 of 306 [55.9%]) underwent TDL. A larger proportion of patients in group A required TDL compared with group B (72.6% versus 30.0%, P < 0.001). Group A had a significantly higher rate of overall morbidity compared with group B (31.7% versus 19.2%, P = 0.02). Moreover, the overall mortality rate was significantly higher in group A (14.0% versus 4.2%, P = 0.006). Chylothorax recurred in nine patients (9 of 306 [2.9%]), and there was no difference between the two groups (3.2% versus 2.5%, P = 1.000).

Conclusions

The 2-wk regimen reduced the requirement for TDL and the overall morbidity and mortality rates compared with the 48-h regimen. Importantly, this regimen does not increase the risk of chylothorax recurrence.     

Morbidity of peripherally inserted central catheters in pediatric complicated appendicitis

Background

The purpose of this study was to compare postoperative outcomes of pediatric patients with complicated appendicitis managed with or without a peripherally inserted central catheter (PICC).

Methods

Patients aged ≤18 y in the Pediatric Health Information System database with complicated appendicitis that underwent appendectomy during their index admission in 2000–2012 were grouped by whether they had a PICC placed using relevant procedure and billing codes. Rates of subsequent encounters within 30 d of discharge along with associated diagnoses and procedures were determined. A propensity score–matched (PSM) analysis was performed to account for differences in baseline exposures and severity of illness.

Results

We included 33,482 patients with complicated appendicitis; of whom, 6620 (19.8%) received a PICC and 26,862 (80.2%) did not. The PICC group had a longer postoperative length of stay (median 7 versus 5 d, P < 0.001) and were more likely to undergo intra-abdominal abscess drainage during the index admission (14.4% versus 2.1%, P < 0.001), and have a reencounter (17.5% versus 11.4%, P < 0.001) within 30 d of discharge. However, in the PSM cohort (n = 4428 in each group), outcomes did not differ between treatment groups, although the PICC group did have increased odds for the development of other postoperative complications (odds ratio = 3.95, 95% confidence interval: 1.45, 10.71).

Conclusions

After accounting for differences in severity of illness by PSM, patients managed with PICCs had a similar risk for nearly all postoperative complications, including reencounters. Postoperative management of pediatric complicated appendicitis with a PICC is not clearly associated with improved outcomes.     

Comparison of laparoscopic versus open adrenalectomy: results from American College of Surgeons-National Surgery Quality Improvement Project

Background

Although the existing literature suggests that laparoscopic adrenalectomy may be associated with less postoperative morbidity than open adrenalectomy, a comparison of the two approaches has not been published using American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) data. The objective of our analysis was to compare the 30-d outcomes after laparoscopic versus open adrenalectomy using this data source.

Methods

The ACS-NSQIP Participant User Files for 2005–2010 were used for this retrospective analysis, which included all patients with (1) a primary Current Procedural Terminology code for open or laparoscopic adrenalectomy and (2) a postoperative International Classification of Diseases, Ninth Revision (ICD-9) code for adrenal gland pathology. Primary outcomes were 30-d postoperative mortality, overall complication rate, and length of postoperative hospitalization. The association between surgical approach and primary outcomes were determined after adjusting for a comprehensive array of patient- and procedure-related factors.

Results

A total of 3100 patients were included for analysis (644 undergoing open versus 2456 undergoing laparoscopic adrenalectomy). Patients undergoing a laparoscopic procedure had significantly lower postoperative morbidity and shorter length of stay than patients undergoing an open procedure after adjustment for patient- and procedure-related factors. Similar findings were demonstrated for all indications, including malignancy.

Conclusions

To our knowledge, the present study represents the largest comparison to date of laparoscopic versus open adrenalectomy. Our findings suggest that the laparoscopic approach is associated with sizeable reductions in postoperative morbidity and length of postoperative hospitalization.     

Short-term outcomes of laparoscopically assisted surgery for rectal cancer following neoadjuvant chemoradiotherapy: a single-center experience

Objective

The efficacy of laparoscopic treatment of rectal cancer remains unclear, and little is known about its effect on sphincter preservation. We compared short-term outcomes of laparoscopically assisted and open surgeries following neoadjuvant chemoradiotherapy (CRT) for mid and low rectal cancer.

Methods

This study enrolled 137 patients with mid-low rectal cancer who underwent curative resection, 51 by laparoscopically assisted (Lap group) and 86 by conventional open (Open group) surgeries, following neoadjuvant CRT from July 2007 to July 2012. The clinical and surgical findings of the two groups of patients were prospectively collected and analyzed.

Results

Three patients (5.9%) in the Lap group were converted to an open procedure. The mean operating times were similar in both groups. The Lap group had a significantly higher rate of sphincter preservation (62.7% versus 41.9%, P = 0.018) and significantly lower mean blood loss than the Open group. Mean times to first flatus, start of a normal diet, and overall postoperative hospitalization were longer for open surgery. The complication rate (11.8% versus 31.4%, P = 0.009) was significantly lower in the Lap group. Mean distal resection margin, involvement of the circumferential resection margin (2.0% versus 3.5%, P = 1.000), and mean lymph nodes harvested (12 versus 11; P = 0.242) were equivalent in the two groups.

Conclusions

Laparoscopically assisted surgery following neoadjuvant CRT is safe for patients with rectal cancer and provides favorable short-term benefits but without compromising oncologic outcomes. This sphincter-preserving procedure may be a treatment of choice for patients with lower rectal cancer.     

Laparoscopic versus open colonic resection for complicated diverticular disease in the emergency setting: a safe choice? A retrospective comparative cohort study

Background

We conducted a retrospective cohort study to compare the outcomes of laparoscopic colon resection (LCR) with open colon resection (OCR) for complicated diverticular disease (CDD) during emergent hospital admission.

Methods

Charts from all patients undergoing colon resection for CDD during emergent hospital admission at a single academic institution were reviewed. The primary outcomes were overall 30-day postoperative morbidity and mortality.

Results

From 2000 to 2010, 125 cases were retrieved (49 LCR and 86 OCR). Conversion rate was 5.1%. Overall morbidity significantly decreased with laparoscopic surgery compared with OCR. No mortality occurred with LCR. Prolonged ileus was less frequent (12.8% vs 32.6%; P = .02), time to oral intake shorter (3 vs 6 days; P < .01), and LOS shorter (5 vs 8 days; P = .05) for LCR.

Conclusions

In our series, in the patients selected, LCR for CDD during emergent hospital admission appears to be a safe procedure associated with decreased morbidity, time to oral intake, and LOS compared with OCR.     

The role of clinical care pathways: an experience with distal pancreatectomy

Background

Previous studies have indicated that clinical pathways may shorten hospital length of stay (HLOS) among patients undergoing distal pancreatectomy (DP). Here, we evaluate an institutional standardized care pathway (SCP) for patients undergoing DP.

Materials and methods

A retrospective review of patients undergoing DP from November 2006 to November 2012 was completed. Patients treated before and after implementation of the SCP were compared. Multivariable linear regression was then performed to identify independent predictors of HLOS.

Results

There were no differences in patient characteristics between SCP (n = 50) and pre-SCP patients (n = 100). Laparoscopic technique (62% versus 13%, P < 0.001), splenectomy (52% versus 38%, P = 0.117), and concomitant major organ resection (24% versus 13%, P = 0.106) were more common among SCP patients. Overall, important complication rates were similar (24% versus 26%, P = 0.842). SCP patients resumed a normal diet earlier (4 versus 5 d, P = 0.025) and had shorter HLOS (6 versus 7 d, P = 0.026). There was no increase in 30-d resurgery or readmission. In univariate comparison, SCP, cancer diagnoses, intraductal papillary mucinous neoplasm diagnoses, neoadjuvant therapy, operative technique, major organ resection, and feeding tube placement were associated with HLOS; however, after multivariable adjustment, only laparoscopic technique (−33%, P = 0.001), concomitant major organ resection (+38%, P < 0.001), and feeding tube placement (+68%, P < 0.001) were independent predictors of HLOS.

Conclusions

Implementation of a clinical pathway did not improve HLOS at our institution. The increasing use of laparoscopy likely accounts for shorter HLOS in the SCP cohort. In the future, it will be important to identify clinical scenarios most likely to benefit from implementation of a clinical pathway.