Adding days spent in readmission to the initial postoperative length of stay limits the perceived benefit of laparoscopic distal pancreatectomy when compared with open distal pancreatectomy

doi:10.1016/j.amjsurg.2010.09.014

The American Journal of Surgery

Volume 201, Issue 3, March 2011, Pages 295-300

https://doi.org/10.1016/j.amjsurg.2010.09.014 Get rights and content

Abstract

Background

Published comparisons of laparoscopic (laparoscopic distal pancreatectomy [LDP]) to open distal pancreatectomy (ODP) identify improved lengths of stay (LOS) after LDP but do not include data on readmissions.

Methods

Demographic, operative, and postoperative outcomes data for patients undergoing LDP or ODP between August 2007 and December 2009 were culled from our prospectively accruing pancreatic database. Electronic medical records were reviewed to determine cause, treatment, and LOS for readmissions.

Results

Patients undergoing LDP were statistically identical to those undergoing ODP in regard to age, presentation, demographic characteristics, comorbidities, operative times, tumor sizes, morbidity, mortality, and pancreatic fistula rates. The initial LOS was statistically shorter for those undergoing LDP (4.8 ± .1 days vs 8.7 ± .1 days, P < .001). The readmission rate for LDP was statistically higher than for ODP (25% vs 8%, P < .05). Overall LOS for LDP was 7.2 ± .3 days versus 9.3 ± .1 days for ODP (P = .2).

Conclusions

Adding readmission LOS to initial LOS eliminates the perceived effect of LDP to accelerate recovery.

Section snippets

Study population

We maintain a database for patients who are receiving care in our affiliated tertiary care centers for pancreatic cancer, benign/premalignant pancreatic neoplasms, and acute and chronic pancreatitis. Patients are consented, and data are entered prospectively by a single individual (SS) as the patient receives care. The database tracks 600 preoperative, operative, and postoperative outcome parameters. We queried this database for patients undergoing either LDP or ODP between August 2007 and

Preoperative demographic and clinical comparison

Patients undergoing LDP were more often female (85% vs 50%, P < .05), less likely to have chronic pancreatitis (.0% vs 14.0% P < .05), and had a higher serum protein albumin (3.81 ± .06 mg/dL vs 3.59 mg/dL ± .05 mg/dL, P < .001) than those undergoing ODP (Table 1). There were no other statistically significant differences in regard to the preoperative demographic data and preoperative nonpathological clinical data.

Intraoperative outcomes

On average, the estimated blood loss for those patients undergoing LDP was one

Comments

We describe the pattern of hospital readmission after LDP relative to that after ODP. There are several important findings. The first is that the patients undergoing open and laparoscopic procedures were similar with regard to the preoperative demographic and clinical parameters assessed. The incidence of chronic pancreatitis was certainly higher in the group who underwent open resection but was quite low in both groups. The incidence of malignant pathology was also higher in the open group by

Conclusions

We present a single-institution comparison of laparoscopic to open distal pancreatecotmy with a focus on the pattern of postdischarge readmission after each approach. Both procedures offer reasonable rates of postoperative morbidity. The laparoscopic approach provides a statistically shorter initial length of stay without adding substantially to the operative time but is associated with a higher rate of late readmissions requiring interventional procedures. The overall length of stay for both

References (8)

M.S. Baker et al.
A prospective single institution comparison of peri-operative outcomes for laparoscopic and open distal pancreatectcomy
Surgery
(2009)
C. Bassi et al.
Postoperative Pancreatic Fistula: an International Study Group (ISGPF) Definitision
Surgery
(2005)
T. Matsumoto et al.
Laparoscopic distal pancreatectomy and open distal pancreatectomy: a nonrandomized comparative study
Surg Laparosc Endosc Percutan Tech
(2008)
S.C. Kim et al.
Comparative analysis of clinical outcomes for laparoscopic distal pancreatic resection and open distal pancreatic resection at a single institution
Surg Endosc
(2008)

There are more references available in the full text version of this article.

Cited by (34)

The laparoscopic approach to distal pancreatectomy is a value-added proposition for patients undergoing care in moderate-volume and high-volume centers
2019, Surgery (United States)
Citation Excerpt :
Because of the potential to save lives and the high costs of care associated with both the index operation and its postoperative complications, DP, by nature, represents a unique opportunity to significantly improve value for patients. Studies have evaluated the impact of variations in several technical approaches to the DP on postoperative complication rates, rates of readmission, and lengths of stay.2-4 These have included studies comparing minimally invasive methods with open procedures, use of staplers and various energy devices to divide the pancreatic parenchyma, use of endoscopic stenting to manage pancreatic fistula, and application of sealants to prevent fistula.
Little is known regarding the impact of the minimally invasive approach to distal pancreatectomy on the aggregate costs of care for patients undergoing distal pancreatectomy.
We queried the Healthcare Cost and Utilization Project State Inpatient Database to identify patients undergoing elective laparoscopic distal pancreatectomy or open distal pancreatectomy between 2012 and 2014. Multivariable regression was used to evaluate postoperative outcomes including readmissions to 90 days after distal pancreatectomy.
A total of 267 (11%) patients underwent laparoscopic distal pancreatectomy, and a total of 2,214 (89%) underwent open distal pancreatectomy. On multivariable regression, patients undergoing laparoscopic distal pancreatectomy had a decreased odds risk of having any severe adverse outcome (odds ratio 0.73, 95% confidence interval [0.54–0.97]), prolonged length of stay (odds ratio 0.49, 95% confidence interval [0.30–0.79]), and of being in the highest quartile for aggregate costs of care (odds ratio 0.46, 95% confidence interval [0.32–0.66]) relative to those undergoing open distal pancreatectomy. Patients undergoing laparoscopic distal pancreatectomy had a lower average 90-day aggregate cost of care than those undergoing open distal pancreatectomy when procedures were performed in high-volume (–$16,153, 95% CI: [–$23,342 to –$8,964]) centers.
Patients undergoing laparoscopic distal pancreatectomy have a lower risk of severe adverse outcomes, prolonged overall length of stay, and lower associated costs of care relative to those undergoing open distal pancreatectomy. This association is independent of hospital volume.
Risk factors for early readmission after total pancreatectomy and islet auto transplantation
2018, HPB
Little published data exist examining causes of hospital readmission following total pancreatectomy with islet autotransplantation (TPIAT).
A retrospective analysis was performed of a prospectively collected institutional TPIAT database. Primary outcome was unplanned readmission to the hospital within 30 days from discharge. Reasons and risk factors for readmission as well as islet function were evaluated and compared by univariate and multivariate analysis.
83 patients underwent TPIAT from 2006 to 2014. 21 patients (25.3%) were readmitted within 30 days. Gastrointestinal problems (52.4%) and surgical site infection (42.8%) were the most common reasons for readmission. Initial LOS and reoperation were risk factors for early readmission. Patients with delayed gastric emptying (DGE) were three times more likely to get readmitted. In multivariate analysis, patients undergoing pylorus preservation surgery were nine times more likely to be readmitted than the antrectomy group.
Early readmission after TPIAT is common (one in four patients), underscoring the complexity of this procedure. Early readmission is not detrimental to islet graft function. Patients undergoing pylorus preservation are more likely to get readmitted, perhaps due to increased incidence of delayed gastric emptying. Decision for antrectomy vs. pylorus preservation needs to be individualized.
Surgical Management of Pancreatic Neuroendocrine Tumors
2016, Surgical Clinics of North America
Citation Excerpt :
Formal pancreatic resection is recommended when enucleation cannot be accomplished and is based on tumor location (ie, head, body, tail). Laparoscopic distal pancreatectomy has been shown to be safe, and short-term outcomes may be favorable with this approach over an open approach.63–65,67,68 Several techniques have been described including spleen-preserving (eg, Warshaw technique) and spleen-sacrificing methods of laparoscopic distal pancreatectomy.69
Robotic versus laparoscopic distal pancreatectomy – The first meta-analysis
2016, HPB
Citation Excerpt :
There is a strong possibility for underreporting bias because patients admitted in another hospital may not have been reported. It was reported that the increased readmission rate of LPD limits its perceived benefit compared with the open technique.20 Yet, Rutz et al. compared the 30-day readmissions of LDP and the open technique and reported that the former is more cost-effective than the latter.21
Minimally invasive pancreaticoduodenectomy is considered hazardous for the majority of authors and minimally distal pancreatectomy is still a debated topic. The aim of this study was to compare robotic distal pancreatectomy (RDP) versus laparoscopic distal pancreatectomy (LDP) using meta-analysis.
EMBASE, Medline and PubMed were searched systematically to identify full-text articles comparing robotic and laparoscopic distal pancreatectomies. The meta-analysis was performed by using Review Manager 5.3.
Nine studies fulfilled the inclusion criteria and included 637 patients (246 robotic and 391 laparoscopic). RDP had a shorter hospital length of stay by 1 day (P = 0.01). On the other hand, LDP had shorter operative time by 30 min, although this was statistically nonsignificant (P = 0.12). RDP showed a significantly increased readmission rate (P = 0.04). There was no difference in the conversion rate, incidence of postoperative pancreatic fistula, International Study Group of Pancreatic Fistula grade B–C rate, major morbidity, spleen preservation rate and perioperative mortality. All surgical specimens of RDP reported R0 negative margins, whereas 7 specimens in the LDP group had affected margins.
In terms of feasibility, safety and oncological adequacy, there is no essential difference between the two techniques so far. The 30 min longer operative time of the RDP is due to the docking and undocking of the robot. The shorter length of stay by 1 day should be judged in combination with the increased 90-day readmission rate.
General and vascular surgery readmissions: A systematic review
2014, Journal of the American College of Surgeons
Predicting the risks of venous thromboembolism versus post-pancreatectomy haemorrhage: Analysis of 13 771 NSQIP patients
2014, HPB
The fear of an early post-pancreatectomy haemorrhage (PPH) may prevent surgeons from prescribing post-operative venous thromboembolism (VTE) chemoprophylaxis. The primary hypothesis of this study was that the national post-pancreatectomy early PPH rate was lower than the rate of VTE. The secondary hypothesis was that patients at high risk for post-discharge VTE could be identified, potentially facilitating the selective use of extended chemoprophylaxis.
All elective pancreatectomies were identified in the 2005 to 2010 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database. Factors associated with 30-day rates of (pre- versus post-discharge) VTE, early PPH (transfusions > 4 units within 72 h) and return to the operating room (ROR) with PPH were analysed.
Pancreaticoduodenectomies (PD) and distal pancreatectomies (DP) numbered 9140 (66.4%) and 4631 (33.6%) out of 13 771 pancreatectomies, respectively. Event rates included: VTE (3.1%), PPH (1.1%) and ROR+PPH (0.7%). PD and DP had similar VTE rates (P > 0.05) with 31.9% of VTE occurring post-discharge. Independent risk factors for late VTE included obesity [odds ratio (OR), 1.5], age ≥ 75 years (OR, 1.8), DP (OR, 2.4) and organ space infection (OR, 2.1) (all P < 0.02).
Within current practice patterns, post-pancreatectomy VTE outnumber early haemorrhagic complications, which are rare. The fear of PPH should not prevent routine and timely post-pancreatectomy VTE chemoprophylaxis. Because one-third of VTE occur post-discharge, high-risk patients may benefit from post-discharge chemoprophylaxis.

View all citing articles on Scopus

View full text

Midwest Surgical AssociationAdding days spent in readmission to the initial postoperative length of stay limits the perceived benefit of laparoscopic distal pancreatectomy when compared with open distal pancreatectomy

Abstract

Background

Methods

Results

Conclusions

Section snippets

Study population

Preoperative demographic and clinical comparison

Intraoperative outcomes

Comments

Conclusions

Surgery

Surgery

Laparoscopic distal pancreatectomy and open distal pancreatectomy: a nonrandomized comparative study

Surg Laparosc Endosc Percutan Tech

Comparative analysis of clinical outcomes for laparoscopic distal pancreatic resection and open distal pancreatic resection at a single institution

Surg Endosc

Midwest Surgical Association
Adding days spent in readmission to the initial postoperative length of stay limits the perceived benefit of laparoscopic distal pancreatectomy when compared with open distal pancreatectomy