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OBJECTIVES Established systems for grading postoperative complications do not change the assigned grade when multiple interventions or readmissions are required to manage the complication. We seek to define a quality outcome for distal pancreatectomy(DP) and determine if laparoscopic distal pancreatectomy(LDP) affords an improvement in quality relative to open distal pancreatectomy(ODP).

METHODS Inpatient and office charts for patients undergoing either ODP or LDP between January 2006 and December 2009 were reviewed to capture all complications and 90-day readmission events. Clavien-Dindo grade IIIb, IV and V complications were classified as severe adverse postoperative outcomes(SAPO). II and IIIa complications requiring either prolonged overall lengths of stay(>2 standard deviations beyond the mean for patients undergoing ODP without complication) including readmissions or more than one interventional procedure were also classified as SAPOs. All others were considered minor adverse outcomes(MAPO).

RESULTS 127 patients underwent DP. 63 (49%) had a complication. 91% of DP patients had a complication of low/moderate Clavien-Dindo grade(I, II, IIIa) or no complication. Using our re-classification, however, 24.8% had what was considered to be a poor quality outcome(SAPO) while 75.2% had a high quality outcome(MAPO or no complication). Of the patients undergoing DP, 77 underwent ODP and 50 underwent LDP. Compared to patients undergoing ODP, patients undergoing LDP were statistically less likely to have ductal adenocarcinoma(4% vs. 26%, p<0.01) and tended to have smaller tumors(3.1+0.36 cm vs. 3.9+0.26 cm, p=0.05). Those undergoing LDP did also demonstrate, however, lower volumes of intraoperative blood loss (234+30.1 mLs vs 752+152.7 mLs, p<0.01), lower rates of postoperative transfusion (2% vs 20%, p<0.01), lower rates of postoperative morbidity (35% vs 58%, p<0.01), shorter initial postoperative lengths of stay (4.1+0.23 vs 8.3+0.7 days, p<0.01), shorter overall lengths of stay including 90-day readmissions (6.1+0.9 days vs. 10.51+0.9 days, p<0.01), and were less likely to have a poor quality(SAPO) outcome(15% vs 31%, p=0.02)than those undergoing ODP. There were no statistical differences between the two groups in regard to age, presenting symptoms, incidence of diabetes, chronic pancreatitis or comorbid cardiopulmonary disease, preoperative albumin, operative time, the rate of readmission or of pancreatic fistula.

CONCLUSIONS Generic grading systems underestimate the severity of some complications following distal pancreatectomy. Using a procedure specific metric for quality following distal pancreatectomy, LDP affords a higher quality postoperative outcome than ODP resulting in shorter initial and overall lengths of stay, a lower incidence of postoperative transfusion and a lower incidence of severe adverse postoperative outcomes.