Categories that account for extent of surgery, complexity, and technical aspects equal better risk stratification

Postoperative outcomes for total pancreatectomy (TP) can be significantly affected by the surgery’s extent, complexity, and technical aspects, a single-center, retrospective review suggests.

As such, classifying TP into four different categories based on these distinguishing features should lead to more accurate postoperative risk stratification as well as comparisons in future studies.

In a cohort of 1,451 patients who had undergone TP at the Heidelberg University Hospital in Heidelberg, Germany, the overall postoperative surgical complication rate was 46% while the overall mortality rate for the entire patient cohort was 3.4% at 30 days and 6.1% at 90 days, Martin Loos, MD, Heidelberg University Hospital, Heidelberg, Germany, and colleagues observed in JAMA Surgery.

However, as reflected by both the median postoperative length of hospital stay and 30-day and 90-day mortality rates, a gradual increase in surgical morbidity was noted for each successively more extensive procedure performed.

“[D]ifferences in [the] extent, complexity, and technical difficulty [of TP] are rarely acknowledged in the literature [so] the comparability of short-term postoperative outcomes after TP is limited,” Loos and colleagues pointed out.

“Our 4-category classification of TP enables a subtler discrimination among different types of TP while remaining simple enough for everyday use,” the authors proposed.

The four proposed categories of TP reflect increasing levels of procedural difficulty:

  • Type 1 standard TP.
  • Type 2 TP with venous resection.
  • Type 3 TP with multivisceral resection.
  • Type 4 TP with arterial resection.

Patients underwent one of the four types of TP between October 2001 and December 2020.

The most frequent indication for TP was pancreatic adenocarcinoma in approximately 60% of patients, followed by intraductal papillary mucinous neoplasms in approximately 15% of the cohort. Most patients underwent standard type 1 TP (46.6%), researchers noted. Another 20.4% underwent type 2 TP, while slightly more patients (21.6%) underwent type 3 TP. A smaller percentage of patients (11.4%) underwent type 4 TP.

Overall surgical morbidity gradually increased with the complexity of TP, investigators observed:

  • Type 1 TP: 37.7%.
  • Type 2 TP: 46.3%.
  • Type 3: 56.7%.
  • Type 4: 59.4%.

The median postoperative length of hospital stay was 15 days (interquartile range (IQR), 11-22 days), they added. However, again, the median length of hospital stay increased as the complexity of the surgical procedure increased:

  • Type 1 TP: 14 days (IQR, 10-19 days).
  • Type 2 TP: 16 days (IQR, 12-23 days).
  • Type 3 TP: 17 days (IQR, 13-29 days).
  • Type 4 TP: 18 days (IQR, 13-30 days).

The same pattern was seen for mortality rates at both 30 and 90 days postoperatively:

  • Type 1 TP: 2.7% at 30 days; 3.4% at 90 days.
  • Type 2 TP: 2.4% at 30 days; 5.7% at 90 days.
  • Type 3 TP: 4.5% at 30 days; 9.2% at 90 days.
  • Type 4 TP: 6.1% at 30 days; 12.1% at 90 days.

Indeed, patients requiring a multivisceral type 3 procedure had a 2.2-fold higher risk of dying within 90 days compared with those who required less extensive surgery, while those who required an arterial resection TP had a 3.6-fold higher 90-day mortality rate compared with patients who could undergo type 1 or type 2 TP.

The study authors also pointed out that overall mortality rates actually dropped to 2.2% at 30 days and 3.7% at 90 days between the years 2017 to 2020 as the use of TP at the Heidelberg center increased rather dramatically.

“[T]he risk for an adverse outcome is not comparable among all TPs and the extent of resection should be acknowledged separately,” Loos and colleagues wrote. “The proposed categorization into 4 different types of TP may be important for operative risk stratification and standardized outcome reporting and also may enhance the comparability of future studies.”

Commenting on the findings, Pauli Puolakkainen, MD, PhD, Helsinki University Hospital, University of Helsinki, Finland, cautioned that emergency pancreatic surgery cases were not included in the current analysis, although elective completion pancreatectomies were.

“Performing TP primarily or after a time period as a secondary operation can be quite different surgical procedures,” the editorialist wrote.

The fact that the authors did include procedures done as a secondary operation was based on their own assessment that functional results are equal and the technical challenges and limitations are comparable, Puolakkainen noted.

However, as he also noted, the median time from the primary operation to elective completion pancreatectomy was 27.2 months in the current series while elsewhere, the time between the primary and the secondarily performed elective completion pancreatectomy may well be shorter than it was in the present study.

“Thus, more evidence on application of the proposed classification is warranted because the operative circumstances can be very different,” the editorialist suggested, adding however, that “[t]he proposed readily applicable categorization of TP may have the potential to be important for better operative risk stratification, standardized outcome reporting and more accurate comparisons of future studies,” the authors proposed.

  1. The extent, complexity, and technique involved in total pancreatectomy can possibly lead to significant differences in postoperative outcomes.

  2. Categorizing pancreatectomy according to these features could help with risk stratification of postoperative outcomes.

Pam Harrison, Contributing Writer, BreakingMED™

Neither the authors nor the editorialist had any conflicts of interest to declare.

Cat ID: 159

Topic ID: 97,159,730,935,192,925,159