• Stijn van Roessel, Tara M Mackay, Susan van Dieren, George P van der Schelling, Vincent B Nieuwenhuijs, Koop Bosscha, Edwin van der Harst, Ronald M van Dam, Liem Mike S L MSL Department of Surgery, Medisch Spectrum Twente, Enschede, The Netherlands., Sebastiaan Festen, Stommel Martijn W J MWJ Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands., Daphne Roos, Fennie Wit, I Quintus Molenaar, Vincent E de Meijer, Geert Kazemier, de Hingh Ignace H J T IHJT Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands., Hjalmar C van Santvoort, Bert A Bonsing, Olivier R Busch, Bas Groot Koerkamp, Marc G Besselink, and Dutch Pancreatic Cancer Group.
• Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
• Ann. Surg. 2020 Jan 1; 271 (1): 155-162.

BackgroundTextbook outcome (TO) is a multidimensional measure for quality assurance, reflecting the "ideal" surgical outcome.MethodsPost-hoc analysis of patients who underwent pancreatoduodenectomy (PD) or distal pancreatectomy (DP) for all indications between 2014 and 2017, queried from the nationwide prospective Dutch Pancreatic Cancer Audit. An international survey was conducted among 24 experts from 10 countries to reach consensus on the requirements for TO in pancreatic surgery. Univariable and multivariable logistic regression was performed to identify TO predictors. Between-hospital variation in TO rates was compared using observed-versus-expected rates.ResultsBased on the survey (92% response rate), TO was defined by the absence of postoperative pancreatic fistula, bile leak, postpancreatectomy hemorrhage (all ISGPS grade B/C), severe complications (Clavien-Dindo ≥III), readmission, and in-hospital mortality. Overall, 3341 patients were included (2633 (79%) PD and 708 (21%) DP) of whom 60.3% achieved TO; 58.3% for PD and 67.4% for DP. On multivariable analysis, ASA class 3 predicted a worse TO rate after PD (ASA 3 OR 0.59 [0.44-0.80]), whereas a dilated pancreatic duct (>3 mm) and pancreatic ductal adenocarcinoma (PDAC) were associated with a better TO rate (OR 2.22 [2.05-3.57] and OR 1.36 [1.14-1.63], respectively). For DP, female sex and the absence of neoadjuvant therapy predicted better TO rates (OR 1.38 [1.01-1.90] and OR 2.53 [1.20-5.31], respectively). When comparing institutions, the observed-versus-expected rate for achieving TO varied from 0.71 to 1.46 per hospital after casemix-adjustment.ConclusionsTO is a novel quality measure in pancreatic surgery. TO varies considerably between pancreatic centers, demonstrating the potential benefit of quality assurance programs.

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