Elsevier

Surgery

Volume 153, Issue 1, January 2013, Pages 86-94
Surgery

Original Communication
The burden of infection for elective pancreatic resections

https://doi.org/10.1016/j.surg.2012.03.026Get rights and content

Background

Infection control is potentially a critical quality indicator but remains incompletely understood, especially in high-acuity gastrointestinal surgery. Our objective was to evaluate the incidence and impact of infections after elective pancreatectomy at the practice level.

Methods

All pancreatectomies performed by three pancreatic surgical specialists over an 8-year period (2001–2009) followed standardized perioperative care, including timely antibiotic administration. Infections were defined according to National Surgery Quality Improvement Program criteria, while complication severity was based on Clavien grade. Clinical and economic outcomes were evaluated and predictors of infection identified by regression analysis.

Results

Of 550 major pancreatic resections, 288 (53%) had some complication, of which 167 (31%) were infectious. Rates of infection differed by type of resection (proximal pancreatectomy > others; P = .029) but not by presence of malignancy. Major infections (Clavien 3–5; n = 62), occurred in 11% of cases. Infection was not the primary cause of death in any patient. Infection was associated with increases in hospital stay, operative times, transfusions, blood loss, intensive care unit use, and readmission (34% vs 12%). Types of infection were as follows: wound infection (14%), infected pancreatic fistula (9%), urinary tract infection (7%), pneumonia (6%), and sepsis (2%). The use of total parenteral nutrition (odds ratio [OR], 7.3), coronary artery disease (OR, 2.1), and perioperative hypotension (OR, 1.6) predicted any infection. Total costs for cases with infection increased grade-for-grade across the Clavien scale, with infection accounting for 38% of the overall cost differential.

Conclusion

Infectious complications occurred frequently, compromising numerous outcomes and increasing costs markedly. These data provide a foundation for understanding the baseline consequences of infection in high-acuity gastrointestinal surgery and offer opportunities for process evaluation and initiatives in infection control at the practice level.

Section snippets

Methods

Under an institutional review board–approved protocol, data on all pancreatectomies performed by three pancreatic surgical specialists over an 8-year period (2001–2009) were entered prospectively into a comprehensive database and reviewed subsequently. Standardized perioperative care was followed for all patients, according to a Carepath for Pancreatic Resection,6, 7 which organizes and details the multidisciplinary management of those patients. The Carepath includes plans for preoperative

Results

Of 550 major pancreatic resections performed (356 pancreatoduodenectomies [167 distal, 11 total, and 16 other), 288 (53%) had some complication, of which 167 (31%) were infectious. Rates of infection differed by type of resection with pancreatoduodenectomy having the greatest rate of infections (P = .029). Neither age, sex, nor the presence of malignancy was associated with the development of an IC (Table I). Nonelective admission was not associated with higher IC rates. Patients with any IC

Discussion

Mortality after pancreatic resection has decreased greatly, from 33% for the quarter-century after the initial report by Whipple to currently <5% in most high-volume centers.13 In the series reported here, overall perioperative mortality was 1.5%. Therefore, the assessment of surgical quality for this high-acuity procedure needs additional refinement.6 Birkmeyer et al14 revealed the impact of hospital operative mortality and volume on actual operative mortality for pancreatic cancer resections,

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