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High Performing Whipple Patients: Factors Associated With Short Length of Stay After Open Pancreaticoduodenectomy
Grace C. Lee*, Zhi Ven Fong, Cristina R. Ferrone, Sarah P. Thayer, Andrew L. Warshaw, Keith D. Lillemoe, Carlos Fernandez-Del Castillo
Department of Surgery, Massachusetts General Hospital, Boston, MA
Introduction: In this cost-conscious era of health care reform, much attention has been focused on minimizing length of hospital stay (LOS) and readmission rates after surgical procedures. Despite the decreasing morbidity and mortality of pancreaticoduodenectomy (PD), it continues to be associated with prolonged LOS. As preliminary data of minimally invasive PD emerges, we sought to determine the average LOS after open PD at a high-volume tertiary care hospital in an attempt to set a standard to which minimally invasive PD can be compared. We also determined the factors that could predict "high performance" after PD.
Methods: The demographic, perioperative, and readmission data of 634 consecutive patients who underwent open PD between January 2007 and December 2012 at a single institution were reviewed. "High performers" were defined as patients with a LOS ≤5 days.
Results: The median LOS was 7 days (interquartile range 6-10 days). A total of 61 patients (9.6%) had a LOS ≤5 days and were deemed "high performing". Postoperative delayed gastric emptying, ICU admission, and discharge to a rehabilitation facility each perfectly predicted LOS >5 days. In multivariate logistic regression analysis, neoadjuvant therapy (26.2 vs 15.9%, OR 3.31, p=0.003), epidural success (92.9 vs 85.1%, OR 3.73, p=0.030), epidural duration ≤3 days (40.4 vs 19.5%, OR 2.90, p=0.002), surgery on Thursday or Friday (59.3 vs 46.1%, OR 3.10, p=0.001), and discharge on Monday through Wednesday (80.3 vs 50.7%, OR 6.54, p<0.001) were independently associated with LOS ≤5 days. Age ≤70 years, male gender, Charlson comorbidity index <5, and high surgeon volume were predictive of "high performance" on univariate analysis, but were not significant in the multivariate model. When comparing "high performing" patients to those with LOS>5 days, readmission rate (16.4% vs 22.2%, p=0.298) and time to readmission (5.5 vs 12 days, p=0.661) were not different. Body mass index, diabetes, prior abdominal surgery, prior ERCP, vessel resection, and tumor pathology also did not correlate with LOS.
Conclusion: In our contemporary experience of patients undergoing pancreaticoduodenectomy, median LOS after open PD was 7 days, with a 9.6% rate of "high performers". LOS ≤5 days was associated with neoadjuvant therapy, epidural success, and undergoing surgery at the end of the week. "High performing" patients experienced no difference in readmission rates as a result of their early discharges. Minimally invasive PD should be compared to this high standard for LOS, among other quality metrics, to justify its increased cost and operative duration.
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