Ideal Outcome After Pancreatoduodenectomy

Abstract

Introduction: Assessing outcome after pancreatoduodenectomy among centers and countries requires a broad evaluation which cannot be captured by a single parameter. Previously, two composite outcome measures (Textbook Outcome and Optimal Pancreatic Surgery) for pancreatoduodenectomy have been described from Europe and the United States. These composites were harmonized into one Ideal Outcome (IO). Methods: This analysis is a transatlantic retrospective study (2018-2020) of patients after pancreatoduodenectomy within the registries from North America, Germany, the Netherlands, and Sweden. After three consensus meetings, IO for pancreatoduodenectomy was defined as the absence of all six parameters: (1) in-hospital mortality, (2) severe complications - Clavien Dindo ≥3, (3) postoperative pancreatic fistula - ISGPS grade B/C), (4) reoperation, (5) hospital stay >75th percentile, and (6) readmission. Outcomes were evaluated using relative (RLD) and absolute largest differences (ALD), and multivariate regression models. Results: Overall, 21,036 patients after pancreatoduodenectomy were included, of whom 11,194 (54%) reached IO. The rate of IO varied between 55% in North America, 53% in Germany, 52% in the Netherlands, and 54% in Sweden (RLD: 1.1, ALD: 3%, P<0.001). Individual components varied with an ALD of 2% length of stay, 4% for in-hospital mortality, 12% severe complications, 10% postoperative pancreatic fistula, 11% reoperation, and 9% readmission. Age, sex, absence of COPD, BMI, performance status, ASA score, biliary drainage, absence of vascular resection, and histological diagnosis were associated with IO. In the subgroup of patients with pancreatic adenocarcinoma, country and neoadjuvant chemotherapy also was associated with improved IO. Conclusion: The newly developed composite outcome measure ‘Ideal Outcome’ can be used for auditing and comparing outcomes after pancreatoduodenectomy. The observed differences can be used to guide collaborative initiatives to further improve outcomes of pancreatic surgery.