• J. Am. Coll. Surg. · Jul 2023

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

    • Reed I Ayabe, Laura R Prakash, Morgan L Bruno, Timothy E Newhook, Jessica E Maxwell, Elsa M Arvide, Whitney L Dewhurst, Michael P Kim, Naruhiko Ikoma, Rebecca A Snyder, Jeffrey E Lee, KatzMatthew H GMHG, and TzengChing-Wei DCD.
    • From the Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX.
    • J. Am. Coll. Surg. 2023 Jul 1; 237 (1): 4124-12.

    BackgroundThe use of risk-stratified pancreatectomy care pathways (RSPCPs) is associated with reduced length of stay (LOS). This study sought to evaluate the impact of successive pathway revisions with the hypothesis that high-risk patients require iterative pathway revisions to optimize outcomes.Study DesignA prospectively maintained database (October 2016 to December 2021) was evaluated for pancreaticoduodenectomy patients managed with RSPCPs preoperatively assigned based on postoperative pancreatic fistula (POPF) risk. Launched in October 2016 (version [V] 1), RSPCPs were optimized in February 2019 (V2) and November 2020 (V3). Targeted pathway components included earlier nasogastric tube removal, diet advancement, reduced intravenous fluids and opioids, institution-specific drain fluid amylase cutoffs for early day 3 removal, and patient education. Primary outcome was LOS. Secondary outcomes included major complication (Accordion grade 3+), POPF (International Study Group for Pancreatic Surgery Grade B/C), and delayed gastric emptying (DGE).ResultsOf 481 patients, 234 were managed by V1 (83 high-risk), 141 by V2 (43 high-risk), and 106 by V3 (43 high-risk). Median LOS reduction was greatest in high-risk patients with a 7-day reduction (pre-RSPCP, 12 days; V1, 9 days; V2, 7 days; V3, 5 days), compared with low-risk patients (pre-pathway, 10 days; V1, 6 days; V2, 5 days; V3, 4 days). Complications decreased significantly among high-risk patients (V1, 45%; V2, 33%; V3, 19%; p < 0.001), approaching rates in low-risk patients (V1, 21%; V2, 20%; V3, 14%). POPF (V1, 33%; V2, 23%; V3, 16%; p < 0.001) and DGE (V1, 23%; V2, 22%; V3, 14%; p < 0.001) improved among high-risk patients.ConclusionsRisk-stratified pancreatectomy care pathways are associated with reduced LOS, major complication, Grade B/C fistula, and DGE. The easiest gains in surgical outcomes are generated from the immediate improvement in the patients most likely to be fast-tracked, but high-risk patients benefit from successive application of the learning health system model.Copyright © 2023 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.

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