Implementation of a regional reference center in pancreatic surgery. Experience after 631 procedures

Abstract

Introduction

The main objective of this study is to determine whether our unit meets the quality standards required by the scientific community from the reference centers for pancreatic surgery in terms of peri-operative results. The secondary objectives are to compare the different pancreatic surgery techniques performed in terms of early post-operative morbidity and mortality and to analyze the impact of the resections added in these terms.

Method

Descriptive, retrospective and single-center study, corresponding to the period 2006−2019. The results obtained were compared with the proposed quality standards, by Bassi et al. and Sabater et al., required from the reference centers in pancreatic surgery. The sample was divided according to surgical technique and compared in terms of early post-operative morbidity and mortality, studying the impact of extended vascular and visceral resections. All patients undergoing pancreatic surgery in our unit due to pancreatic, malignant and benign pathology were included, since it was implemented as a reference center. Emergency procedures were excluded.

Results

631 patients were analyzed. The values ​​obtained in the quality standards are in range. The most frequent surgery was pancreaticoduodenectomy, which associated higher peri-operative morbidity and mortality rates (P ≤ .05). The extended vascular resections impacted the pancreaticoduodenectomy group, associating a longer mean stay (P = .01) and a higher rate of re-interventions (P = .02).

Conclusions

The experience accumulated allows to meet the required quality standards, as well as perform extended resections to pancreatectomy with good results in terms of post-operative morbidity and mortality.

Resumen

Introducción

El objetivo principal de este estudio es determinar si la Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante Hepático del Hospital Universitario de Badajoz cumple los estándares de calidad exigidos por la comunidad científica a los centros de referencia de cirugía pancreática (CP) en términos de resultados perioperatorios. Los objetivos secundarios consisten en comparar las diferentes técnicas de CP realizadas en función de la morbimortalidad postoperatoria precoz y analizar el impacto de las resecciones extendidas en dichos términos.

Método

Estudio descriptivo, retrospectivo y unicéntrico, correspondiente al periodo 2006−2019. Se compararon los resultados obtenidos con los estándares de calidad propuestos por Bassi et al. y Sabater et al., exigidos a los centros de referencia en cirugía pancreática. La muestra se dividió según técnica quirúrgica y se compararon en términos de morbimortalidad postoperatoria precoz, estudiando el impacto de las resecciones vasculares y viscerales extendidas. Se incluyeron todos los pacientes sometidos a cirugía pancreática en nuestra unidad por patología pancreática, maligna y benigna, desde que ésta se implementó como centro de referencia. Se excluyeron las realizadas de urgencia.

Resultados

Se analizaron 631 pacientes. Los valores obtenidos en los estándares de calidad se encuentran en rango. La cirugía más frecuente fue duodenopancreatectomía cefálica, la cual asoció mayor tasa de morbimortalidad perioperatoria (P ≤ ,05). Las resecciones vasculares añadidas impactaron en el grupo de duodenopancreatectomía cefálica asociando mayor estancia media (P = ,01) y mayor tasa de reinteEVRnción (P = ,02).

Conclusiones

La experiencia acumulada permite cumplir con los estándares de calidad exigidos, así como realizar resecciones extendidas a la pancreatectomía con buenos resultados en términos de morbimortalidad postoperatoria.

Introduction

Although postoperative mortality is currently around 5% in high-volume pancreatic surgery (PS) centers1, 2, morbidity continues to be high, reaching rates up to 60%3, 4. Regardless of the general surgical complications associated with any procedure, PS presents specific complications: delayed gastric emptying (DGE), pancreatic fistula (PF) and post-pancreatectomy hemorrhage (PPH), with associated incidences of 19%–7%⁵, 2%–20%⁶ and 1%–8%⁷, respectively.

Sabater et al.⁸ established the required quality standards for oncological PS, proposing rates of resectability >58%, morbidity <73% and mortality <10%, with associated rates of biliary fistula (BF) <14%, PF< 29%, PPH< 21% and reoperation <20%, with a mean stay <21 days.

The three most common types of PS are pancreaticoduodenectomy (PD), distal pancreatectomy (DP), and total pancreatectomy (TP). The postoperative morbidity rate associated with PD is 50%–60%, with a mortality rate of 5%⁹; TP associates a morbidity of 59.3% and mortality 2.1%¹⁰; DP is the group with the lowest morbidity and mortality rates, at 18% and 0.6%¹¹, respectively.

The main objective of this study is to determine whether the Hepato-Biliary-Pancreatic Surgery and Liver Transplantation Unit of the Hospital Universitario de Badajoz meets the quality standards required by the medical community for PS reference centers in terms of perioperative results. The secondary objectives are to compare the different PS techniques performed in terms of early postoperative morbidity and mortality rates and to analyze the impact of extended resections in these terms.