LONG-TERM COMPLICATIONS AFTER PANCREATICODUODENECTOMY: INCIDENCE, OUTCOMES AND RISK FACTORS
James A. Brown*1, Mazen Zenati1, Amr Al Abbas1, Asmita Chopra1, Katelyn Smith1, Melissa E. Hogg2, Herbert J. Zeh3, Amer H. Zureikat1
1Surgical Oncology, University of Pittsburgh School of Medicine, Pittsburgh, PA; 2Northshore University Health System, Evanston, IL; 3University of Texas Southwestern Medical Center, Dallas, TX
Background
Long-term complications following pancreaticoduodenectomy (PD) can significantly impact quality of life, while increasing healthcare utilization and cost. Most reports focus on short-term (within 90 days) or oncologic outcomes following PD, however incidence and risk factors for long-term complications remain unknown. This study sought to identify the incidence, outcomes and risk factors for long-term (>90 days) complications post-PD.
Methods
All PDs performed between 2010 and 2017 were identified from a single institutional database. Long-term complications including biliary stricture, cholangitis, pancreatitis, new onset DM, exocrine insufficiency, peptic ulcer, small bowel obstruction, and incisional hernia were identified. The cohort was divided into two groups: periampullary adenocarcinomas and indolent/benign/premalignant diseases. To account for the impact of death from cancer recurrence and varying follow-up times, Kaplan-Meier "complication-free"? survival estimates were calculated, treating death or complication as adverse events. Cox regression was used to identify predictors of complication-free survival in both groups.
Results
Of 906 PDs, 259 (28.6%) experienced at least one complication. Interventions for long-term complications were required in 127 (14.0%) patients of which 28 (3.1%) were percutaneous, 55 (6.1%) endoscopic, and 69 (7.6%) surgical; 13 patients (1.4%) required two interventions and 6 (0.7%) required three. Median follow-up was 48.3 months (95% CI = 45.5, 52.5). Incidence and median time-to-event for specific complications were: biliary stricture = 32 cases (3.5%) at 362 days, cholangitis = 57 (6.3%) at 322 days, pancreatitis = 36 (4.0%) at 456 days, DM = 59 (6.5%) at 395 days, exocrine insufficiency = 640 (70.6%) at 43 days, peptic ulcer = 25 (2.8%) at 509 days, SBO = 32 (3.5%) at 408 days, and incisional hernia = 120 (13.3%) at 362 days. Median complication-free survival was 21 months (95% CI: 19, 23). Predictors of complication-free survival for the indolent/benign group were female sex (HR 0.71), BMI>30 (HR 1.49), index length of stay (HR 1.02), and readmission <90 after PD (HR 1.81) (overall model p<0.001). Predictors of complication-free survival for the periampullary cancer cohort were preoperative Charlson Comorbidity Index (HR 1.15), robotic PD (HR 0.82), conversion from minimally invasive to open PD (HR 2.16), nodal stage (HR 1.72), clinically significant pancreatic leak (HR 1.24), and adjuvant therapy (HR 0.77) (overall model p<0.001)
Conclusion
In the largest cohort study to examine the incidence and predictors of several long-term sequelae post-PD, long-term complications occurred in nearly 30% and 14% required an intervention. Several predictors of long-term complications were identified. These findings may serve as a useful adjunct in shared decision making for patients and surgeons considering PD.
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