Targeting Early Deaths Following Pancreaticoduodenectomy to Improve Survival
Whalen Clark*1,2, Natalie Donn1,2, Farhaad C. Golkar1,2, Melissa Silva1,2, Harold Paul1,2, Kenneth Luberice1,2, Jonathan M. Hernandez1,2, Sharona B. Ross1,2, Leigh Ann Humphries1,2, Alexander S. Rosemurgy1,2
1Surgery, University of South Florida, Tampa, FL; 2Tampa General Hospital, Tampa, FL
Introduction: Increasing focus on outcomes with disease specific therapies encourages referrals to centers with optimal outcomes. Strategies to improve survival after pancreaticoduodenectomy must address early mortality to improve long-term survival. This study was undertaken to analyze early mortality after pancreaticoduodenectomy as part of a strategy to improve long-term outcome.Methods: 1031 patients who underwent pancreaticoduodenectomy at a university affiliated hospital from 1992 - 2010 were studied. Medium data are reported. Results: 58 (5.6%) patients, 60% male and age 72 years, died within 90 days after pancreaticoduodenectomy. All patients had a least one significant comorbidity; significant comorbidities were cardiorespiratory (N=86), endocrine (N=26), gastrointestinal (N=47), hematologic (N=8), or other (N=14). 60% of patients had depressed serum albumin levels and 43% were jaundiced. ASA Class was: 17% Class II, 72% Class III, and 10% Class IV. 74% had malignant disease, 17% had pre-malignant diseases, and 10% had benign disease. 22% of patients underwent a major vascular resection or colon resection at the time of pancreaticoduodenectomy. Causes of death were cancer progression/cachexia (9%), cardiorespiratrory failure (17%), leak/perforation (10%), infection (7%), vascular/bleeding (26%), or other (5%). Of all deaths, early deaths (i.e., <30 days) are more likely due to cardiorespiratory disease (21%), leak/perforation (17%), and vascular/bleeding complications (31%), and later deaths (i.e., 31 - 90 days) are most likely associated with progression of cancer/cachexia (10%), cardiorespiratory disease (13%), or vascular/bleeding (21%). Conclusions: Death within 90 days after pancreaticoduodenectomy is uncommon, occurs in relatively older deconditioned patients, and is generally not causally related to underlying malignancy. Early death is generally associated with vascular or bleeding complications. Strategies to minimize early death should focus on careful patient selection and prompt recognition and management of herald bleeding or vascular thrombosis, as it can often result in perioperative death following pancreaticoduodenectomy.
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