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Thomas K. Maatman*, Kyle A. Lewellen, Katelyn Flick, Sean P. McGuire, James Butler, Eugene P. Ceppa, Michael G. House, Attila Nakeeb, Trang Nguyen, Alexandra M. Roch, C. Max Schmidt, Nicholas J. Zyromski
Surgery, Indiana University, Indianpolis, IN

Patients with chronic pancreatitis (CP) localized to the body/tail of the pancreas may benefit from distal pancreatectomy (DP). Chronic inflammatory changes can make surgery technically challenging and CP-associated comorbidities increase postoperative morbidity and mortality risk. Regionalization of care and increased application of minimally invasive techniques may correlate to improved postoperative outcomes; however, nationwide trends in postoperative outcomes after DP for CP have not been evaluated. We hypothesized that outcomes after distal pancreatectomy for chronic pancreatitis have improved over time.

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) identified patients that underwent DP (with or without splenectomy) for CP between 2006 and 2020. Major morbidity was defined as Clavien-Dindo grade III complications or higher. Incidence and risk factors for major morbidity and mortality were evaluated with the chi-squared test, Student's t-test, and multivariable binary logistic regression. Three time periods were compared to analyze trends in outcomes (2006-2010, 2011-2015, and 2016-2020). P values <0.05 were accepted as statistically significant.

From 2006 to 2020, 980 patients underwent DP for CP. Mean age was 52±13 years, most patients were male (n = 538, 54.9%), and mean BMI was 27.1±6.4 kg/m2. Common comorbidities included tobacco use (42.4%), diabetes mellitus (31.1%), and recent weight loss (10.6%). Mean operative time was 226±107 minutes and mean postoperative length of stay (LOS) was 7.7±6.8 days. Rates of 30-day morbidity, major morbidity, and mortality were 36.5% (n = 358), 14.5% (n = 142), and 0.5% (n = 5), respectively. On multivariable analysis, major morbidity was associated with increasing BMI (odds ratio: 1.033, 95% confidence interval: 1.002-1.065, p = 0.04) and serum creatinine (1.444, 1.003-2.077, p = 0.048) and decreasing serum albumin (0.516, 0.386-0.690, p < 0.001). Albumin <3.55 mg/dL was associated with increased rates of major morbidity (22.8% vs. 10.5%, p < 0.001). Over time, improvements were observed in postoperative venous thromboembolism and LOS (Table 1). 30-day morbidity, major morbidity, and mortality were comparable among time periods (Figure 1). The ACS-NSQIP risk calculator underestimated the risk of morbidity but accurately assessed mortality risk after DP for CP.

Morbidity and mortality rates after distal pancreatectomy for chronic pancreatitis remained unchanged over the last 15 years. The ACS-NSQIP risk calculator accurately predicted postoperative mortality, but underestimated morbidity. Preoperative serum albumin concentration <3.55 mg/dL was associated with increased rates of postoperative morbidity, highlighting an opportunity for optimization in chronic pancreatitis patients prior to distal pancreatectomy.

Table 1. Postoperative outcomes after distal pancreatectomy for chronic pancreatitis. Abbreviations: SSI – surgical site infection; UTI – urinary tract infection; MI – myocardial infarction; VTE – venous thromboembolism

Figure 1. Morbidity, major morbidity, mortality, and predicted morbidity/mortality after distal pancreatectomy for chronic pancreatitis. Predicted morbidity and mortality calculated using the ACS-NSQIP risk calculator.

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