Differential Gains in Surgical Outcomes for High-Risk vs Low-Risk Pancreaticoduodenectomy with Successive Refinements of Risk-Stratified Care Pathways

Classification of Post-pancreatectomy Readmissions and Opportunities for Targeted Mitigation Strategies

OBJECTIVE

Within a learning health system paradigm, this study sought to evaluate reasons for readmission to identify opportunities for improvement.

BACKGROUND

Post-pancreatectomy readmission rates have remained constant despite improved index hospitalization metrics.

METHODS

We performed a single-institution case-control study of consecutive patients with pancreatectomy (October 2016 to April 2022). Complications were prospectively graded in biweekly faculty and advanced practice provider meetings. We analyzed risk factors during index hospitalization and categorized indications for 90-day readmissions.

RESULTS

A total of 835 patients, median age 65 years and 51% (427/835) males, underwent 64% (534/835) pancreatoduodenectomies, 34% (280/835) distal pancreatectomies, and 3% (21/835) other resections. Twenty-four percent (204/835) of patients were readmitted. The primary indication for readmission was technical in 51% (105/204), infectious in 17% (35/204), and medical/metabolic in 31% (64/204) of patients. Procedures were required in 77% (81/105) and 60% (21/35) of technical and infectious readmissions, respectively, while 66% (42/64) of medical/metabolic readmissions were managed noninvasively. During the index hospitalization, benign pathology [odds ratio (OR): 1.8, P =0.049], biochemical pancreatic leak (OR: 2.3, P =0.001), bile/gastric/chyle leak (OR: 6.4, P =0.001), organ-space infection (OR: 3.4, P =0.007), undrained fluid on imaging (OR: 2.4, P =0.045), and increasing white blood cell count (OR: 1.7, P =0.045) were independently associated with odds of readmission.

CONCLUSIONS

Most readmissions following pancreatectomy were technical in origin. Patients with complications during the index hospitalization, increasing white blood cell count, or undrained fluid before discharge were at the highest risk for readmission. Predischarge risk stratification of readmission risk factors and augmentation of in-clinic resources may be strategies to reduce readmission rates.

Postoperative Global Period Cost Reduction Using 3 Successive Risk-Stratified Pancreatectomy Clinical Pathways

BACKGROUND

We hypothesized that iterative revisions of our original 2016 risk-stratified pancreatectomy clinical pathways would be associated with decreased 90-day perioperative costs.

STUDY DESIGN

From a single-institution retrospective cohort study of consecutive patients with 3 iterations: "version 1" (V1) (October 2016 to January 2019), V2 (February 2019 to October 2020), and V3 (November 2020 to February 2022), institutional data were aggregated using revenue codes and adjusted to constant 2022-dollar value. Grand total perioperative costs (primary endpoint) were the sum of pancreatectomy, inpatient care, readmission, and 90-day global outpatient care. Proprietary hospital-based costs were converted to ratios using the mean cost of all hospital operations as the denominator.

RESULTS

Of 814 patients, pathway V1 included 363, V2 229, and V3 222 patients. Accordion Grade 3+ complications decreased with each iteration (V1: 28.4%, V2: 22.7%, and V3: 15.3%). Median length of stay decreased (V1: 6 days, interquartile range [IQR] 5 to 8; V2: 5 [IQR 4 to 6]; and V3: 5 [IQR 4 to 6]) without an increase in readmissions. Ninety-day global perioperative costs decreased by 32% (V1 cost ratio 12.6, V2 10.9, and V3 8.6). Reduction of the index hospitalization cost was associated with the greatest savings (-31%: 9.4, 8.3, and 6.5). Outpatient care costs decreased consistently (1.58, 1.41, and 1.04). When combining readmission and all outpatient costs, total "postdischarge" costs decreased (3.17, 2.59, and 2.13). Component costs of the index hospitalization that were associated with the greatest savings were room or board costs (-55%: 1.74, 1.14, and 0.79) and pharmacy costs (-61%: 2.20, 1.61, and 0.87; all p < 0.001).

CONCLUSIONS

Three iterative risk-stratified pancreatectomy clinical pathway refinements were associated with a 32% global period cost savings, driven by reduced index hospitalization costs. This successful learning health system model could be externally validated at other institutions performing abdominal cancer surgery.

Prophylactic Antibiotic Duration and Infectious Complications in Pancreatoduodenectomy Patients With Biliary Stents: Opportunity for De-escalation

OBJECTIVE

The aim of this study was to compare infectious complications in pancreatoduodenectomy (PD) patients with biliary stents treated with short, medium, or long durations of prophylactic antibiotics.

BACKGROUND

Pre-existing biliary stents have historically been associated with higher infection risk after PD. Patients are administered prophylactic antibiotics, but the optimal duration remains unknown.

METHODS

This single-institution retrospective cohort study included consecutive PD patients from October 2016 to April 2022. Antibiotics were continued past the operative dose per surgeon discretion. Infection rates were compared by short (≤24 h), medium (>24 but ≤96 h), and long (>96 h) duration antibiotics. Multivariable regression analysis was performed to evaluate associations with a primary composite outcome of wound infection, organ-space infection, sepsis, or cholangitis.

RESULTS

Among 542 PD patients, 310 patients (57%) had biliary stents. The composite outcome occurred in 28% (34/122) short, 25% (27/108) medium, and 29% (23/80) long-duration ( P =0.824) antibiotic patients. There were no differences in other infection rates or mortality. On multivariable analysis, antibiotic duration was not associated with infection rate. Only postoperative pancreatic fistula (odds ratio 33.1, P <0.001) and male sex (odds ratio 1.9, P =0.028) were associated with the composite outcome.

CONCLUSIONS

Among 310 PD patients with biliary stents, long-duration prophylactic antibiotics were associated with similar composite infection rates to short and medium durations but were used almost twice as often in high-risk patients. These findings may represent an opportunity to de-escalate antibiotic coverage and promote risk-stratified antibiotic stewardship in stented patients by aligning antibiotic duration with risk-stratified pancreatectomy clinical pathways.

Utilizing risk-stratified pathways to personalize post-hepatectomy discharge planning: A contemporary analysis of 1,354 patients

BACKGROUND

While risk-stratified post-hepatectomy pathways (RSPHPs) reduce length-of-stay, can they stratify hepatectomy patients by risk of early postoperative events.

METHODS

90-day outcomes from consecutive hepatectomies were analyzed (1/1/2017-12/31/2021). Pre/post-pathway analysis was performed for pathways: minimally invasive surgery ("MIS"); non-anatomic resection/left hepatectomy ("low-intermediate risk"); right/extended hepatectomy ("high-risk"); "Combination" operations. Time-to-event (TTE) analyses for readmission and interventional radiology procedures (IRPs) was performed.

RESULTS

1354 patients were included: MIS/n= ​119 (9 ​%); low-intermediate risk/n= ​443 (33 ​%); high-risk/n= ​328 (24 ​%); Combination/n= ​464 (34 ​%). There was no difference in readmission (pre: 13 ​% vs. post:11.5 ​%, p ​= ​0.398). There were fewer readmissions in post-pathway patients amongst MIS, low-intermediate risk, and Combination patients (all p ​> ​0.1). 114 (8.4 ​%) patients required IRPs. Time-to-readmission and time-to-IR-procedure plots demonstrated lower plateaus and flatter slopes for MIS/low-intermediate-risk pathways post-pathway implementation (p ​< ​0.001).

CONCLUSION

RSPHPs can reliably stratify patients by risks of readmission or need for an IR procedure by predicting the most frequent period for these events.

Evaluation and Recalibration of Risk-Stratified Pancreatoduodenectomy Drain Fluid Amylase Removal Criteria

BACKGROUND

Risk-stratified drain fluid amylase cutoff values for postoperative day 1 (POD1) (DFA1) and POD3 (DFA3) can guide early drain removal after pancreatoduodenectomy (PD). The aim of this study was to evaluate and recalibrate cutoff values instituted in Feb 2019 using a prospective sequential cohort.

METHODS

We performed a single-institution prospective cohort study of consecutive patients who underwent pancreatoduodenectomy following implementation of institution-specific DFA cutoffs in February 2019 through April 2022. DFA values, drain removal, and clinically relevant postoperative pancreatic fistulas (CR-POPF) were analyzed. Receiver operating characteristic (ROC) curve analysis determined optimal cutoff values.

RESULTS

In total, 267 patients, 173 (65%) low-risk and 94 (35%) high-risk, underwent 228 (85%) open and 39 (15%) robotic pancreatoduodenectomies. Seven (4%) low-risk patients and 21 (22%) high-risk patients developed CR-POPF. Drains were removed in 147 (55%) patients before/on POD3, with 1 (0.7%) CR-POPF. In low-risk patients, CR-POPF was excluded with 100% sensitivity if DFA1 < 286 (area under curve, AUC = 0.893, p = 0.001) or DFA3 < 97 (AUC = 0.856, p = 0.002). DFA1 < 137 (AUC = 0.786, p < 0.001) or DFA3 < 56 (AUC = 0.819, p < 0.001) were 100% sensitive in high-risk patients. Previously established DFA1 cutoffs of 100 (low-risk) and < 26 (high-risk) were 100% sensitive, while DFA3 cutoffs of 300 (low-risk) and 200 (high-risk) had 57% and 91% sensitivity.

CONCLUSIONS

Within a learning health system, we recalibrated post-PD drain removal thresholds to DFA1 ≤ 300 and DFA3 ≤ 100 for low-risk and DFA1 ≤ 100 and DFA3 ≤ 50 for high-risk patients. This methodology is generalizable to other centers for developing institution-specific criteria to optimize safe early drain removal.

Opioid-Free Discharge After Pancreatic Resection Through a Learning Health System Paradigm

Importance

Postoperative opioid overprescribing leads to persistent opioid use and excess pills at risk for misuse and diversion. A learning health system paradigm using risk-stratified pancreatectomy clinical pathways (RSPCPs) may lead to reduction in inpatient and discharge opioid volume.

Objective

To analyze the outcomes of 2 iterative RSPCP updates on inpatient and discharge opioid volumes.

Design, Setting, and Participants

This cohort study included 832 consecutive adult patients at an urban comprehensive cancer center who underwent pancreatic resection between October 2016 and April 2022, comprising 3 sequential pathway cohorts (version [V] 1, October 1, 2016, to January 31, 2019 [n = 363]; V2, February 1, 2019, to October 31, 2020 [n = 229]; V3, November 1, 2020, to April 30, 2022 [n = 240]).

Exposures

After V1 of the pathway established a baseline and reduced length of stay (n = 363), V2 (n = 229) updated patient and surgeon education handouts, limited intravenous opioids, suggested a 3-drug (acetaminophen, celecoxib, methocarbamol) nonopioid bundle, and implemented the 5×-multiplier (last 24-hour oral morphine equivalents [OME] multiplied by 5) to calculate discharge volume. Pathway version 3 (n = 240) required the nonopioid bundle as default in the recovery room and scheduled conversion to oral medications on postoperative day 1.

Main Outcomes and Measures

Inpatient and discharge opioid volume in OME across the 3 RSPCPs were compared using nonparametric testing and trend analyses.

Results

A total of 832 consecutive patients (median [IQR] age, 65 [56-72] years; 410 female [49.3%] and 422 male [50.7%]) underwent 541 pancreatoduodenectomies, 285 distal pancreatectomies, and 6 other pancreatectomies. Early nonopioid bundle administration increased from V1 (acetaminophen, 320 patients [88.2%]; celecoxib or anti-inflammatory, 98 patients [27.0%]; methocarbamol, 267 patients [73.6%]) to V3 (236 patients [98.3%], 163 patients [67.9%], and 238 patients [99.2%], respectively; P < .001). Total inpatient OME decreased from a median 290 mg (IQR, 157-468 mg) in V1 to 184 mg (IQR, 103-311 mg) in V2 to 129 mg (IQR, 75-206 mg) in V3 (P < .001). Discharge OME decreased from a median 150 mg (IQR, 100-225 mg) in V1 to 25 mg (IQR, 0-100 mg) in V2 to 0 mg (IQR, 0-50 mg) in V3 (P < .001). The percentage of patients discharged opioid free increased from 7.2% (26 of 363) in V1 to 52.5% (126 of 240) in V3 (P < .001), with 187 of 240 (77.9%) in V3 discharged with 50 mg OME or less. Median pain scores remained 3 or lower in all cohorts, with no differences in postdischarge refill requests. A subgroup analysis separating open and minimally invasive surgical cases showed similar results in both groups.

Conclusions and Relevance

In this cohort study, the median total inpatient OME was halved and median discharge OME reduced to zero in association with a learning health system model of iterative opioid reduction that is freely adaptable by other hospitals. These findings suggest that opioid-free discharge after pancreatectomy and other major cancer operations is realistic and feasible with this no-cost blueprint.

Postoperative Opioid Use Is Associated with Increased Rates of Grade B/C Pancreatic Fistula After Distal Pancreatectomy

BACKGROUND

Clinically relevant postoperative pancreatic fistula (CR-POPF) is a major source of morbidity after distal pancreatectomy. This study examined the association between postoperative opioid use and CR-POPF in the context of opioid-sparing postoperative care.

METHODS

A case-control study was performed on consecutive patients who underwent distal pancreatectomy between October 2016 and April 2022 at a single institution. Patients who developed CR-POPF were compared to controls. Multivariable regression modeling was used to identify factors associated with CR-POPF.

RESULTS

A total of 281 patients underwent 187 open, 20 laparoscopic, and 74 robotic-assisted operations. The rate of CR-POPF was 21% (n = 58). CR-POPF rate declined from 32 to 8% over the study period (p < 0.001). Median oral morphine equivalents (OME) administered on POD 0-1 and 0-3 were 94 and 129 mg, respectively, in patients who did not develop a fistula versus 130 and 180 mg in those who did (both p ≤ 0.001). POD 0-3 OME (OR 1.11, p = 0.044) was independently associated with increased odds of CR-POPF, with each additional 50 mg (equivalent to 10 tramadol pills) increasing the relative risk by 11% and absolute risk by 2%.

CONCLUSION

Early postoperative opioid use after distal pancreatectomy was associated with increased odds of CR-POPF. Decreasing perioperative opioid use through enhanced postoperative management is a low-cost and generalizable approach that may reduce rates of CR-POPF after distal pancreatectomy.