Background
Short-term outcomes after major abdominal surgery are influenced by indication, surgical intervention, the surgeons' expertise, hospital volume and perioperative management [
1‐
5]. In order to qualitatively assess the impact of the various factors on outcome, a rigorous means of evaluation such as the randomized controlled trial (RCT) design is necessary. Mortality and morbidity in pancreatic surgery has decreased in high-volume centres in recent years [
6,
7] mainly by virtue of standardised surgical and optimised perioperative management [
8]. In high volume centres, mortality from distal pancreatectomy is as low as 5% while morbidity remains as high as 40% [
7,
9‐
12]. Morbidity is determined by perioperative factors such as bowel preparation, incision type, analgesia, mobilisation, and feeding regimens, amongst other factors [
1]. In addition, long-term survival after pancreatectomy as cancer treatment strongly depends on a centre's operative volume [
13].
A recent study of 617 consecutive pancreatic resections demonstrated local complications to be more frequent than systemic complications [
14]. Thus, the formation of pancreatic fistulas can be considered the most important complication after a pancreatic left resection. Currently, the Study Centre of the German Surgical Society is conducting a large RCT (DISPACT trial, ISRCTN 18452029) to compare the occurrence rates of pancreatic fistula after stapler versus hand-sewn closure of the pancreas after left resections [
15]. Both expert opinions and evidence-based standards were taken into account in the development of the study protocol. The consensus-assisted development of study protocols has proven to be beneficial and may indeed be helpful in identifying when consensus is present but not justified by evidence [
16]. All 23 centres contributing to DISPACT are centres with a substantial caseload of pancreatic left resection (Table
1). The study protocol of DISPACT has been approved by the ethics committees of all participating centres and has been recently published [
15]. Since the DISPACT trial aims to evaluate the effect of two surgical procedures (stapler and hand-sewn closure) on the development of pancreatic fistula, surgical and perioperative standardisation is of special interest. The present study was launched during an investigator meeting to identify the current practices concerning perioperative management amongst the various participating centres. This study aims to identify the level of consensus of relevant factors in perioperative management. In addition, an extensive literature search was conducted to compare findings with current best available evidence.
Table 1
Total pancreatectomies and distal pancreatic resections performed in 2008 at centres taking part in DISPACT Trial
Amsterdam, Netherlands | 76 | 12 | 8 |
Berlin Charité Mitte, Germany | 20 | 12 | 4 |
Berlin Charité Virchow, Germany | 197 | 48 | 20 |
Berlin Lichtenberg, Germany | 38 | 10 | 4 |
Bochum St. Josef, Germany | 214 | 46 | 7 |
Dresden-Friedrichstadt, Germany | 52 | 5 | 2 |
Freiburg, Germany | 83 | 15 | 2 |
Gent, Belgium | 68 | 6 | 3 |
Heidelberg, Germany | 423 | 87 | 45 |
Homburg, Germany | 61 | 10 | - |
Cologne-Merheim, Germany | 25 | 10 | - |
Liverpool, Great Britain | 128 | 13 | 1 |
Ljubljana, Slovenia | 90 | 25 | 10 |
Mannheim, Germany | 71 | 10 | 4 |
Marburg, Germany | 48 | 13 | 1 |
Munich-LMU, Germany | 91 | 19 | 13 |
Munich-TU, Germany | 87 | 27 | 22 |
Regensburg, Germany | 70 | 19 | 6 |
Verona, Italy | 269 | 66 | 17 |
Würzburg, Germany | 20 | 7 | 2 |
Wuppertal, Germany | 24 | 3 | 1 |
Total | 2155 | 463 | 172 |
Median (range) | 71 (20–423) | 13 (3–87) | 4 (0–45) |
Acknowledgements
The authors would like to thank Dylan Parker Rahe and Heather Karner for English language editing.
We highly appreciate the support of all DISPACT trial centres and we would like to thank all doctors who have participated in the survey on peri-operative treatment.: Department of Surgery, Amsterdam Medical Centre, The Netherlands, Prof. D. Gouma, Dr. N. van der Gaag; Department of General, Visceral, Vascular and Thoracic Surgery, Charite Campus Mitte, Berlin, Germany, Prof. J. Müller, PD Dr. T. Junghans; Department of General, Visceral and Transplantation Surgery, Charite Campus Virchow, Berlin, Germany, Prof. P. Neuhaus, PD Dr. Matthias Glanemann; Department of General and Visceral Surgery, Sana Clinical Centre Berlin Lichtenberg, Germany, Prof. K. Gellert, Dr. F. Fritze; Department of General Surgery, St. Josef Hospital, Ruhr University, Bochum, Germany, Prof. W. Uhl, Dr. O. Belyaev; Department of General an Abdominal Surgery, Municipal Clinical Centre Dresden-Friedrichstadt, Germany, Prof. H. Witzigmann, Dr. H. Lauer; Department of General and Visceral Surgery, Albert-Ludwig University, Freiburg, Germany, Prof. U.T. Hopt, Dr. T. Keck; Department of Surgery, University Medical Centre, Gent, Belgium, Prof. X. Rogiers, Dr. F. Berrevoet; Department of General, Visceral and Transplantation Surgery, University Medical Centre, Heidelberg, Germany, Prof. W. Büchler, Dr. N. Rahbari; Department of General, Visceral, Trauma and Pediatric Surgery, University Medical Centre, Homburg/Saar, Germany, Prof. M. Schilling, Dr. J. Schuld; Department of General, Visceral and Trauma Surgery, Hospital of the Augustins gGmbH, Cologne, Germany, Prof. T. Beckurts, Dr. E. Pfisterer; Department of Visceral, Vascular and Transplantation Surgery, Merheim Hospital, Cologne, Germany, Prof. M. Heiss, PD Dr. C. Rudroff; Division of Surgery and Oncology, Royal Liverpool University Hospital, Liverpool, UK, Prof. J.P. Neoptolemos, Dr. M. Raraty; Department of Abdominal Surgery, University Medical Center, Ljubljana, Slovenia, Prof. S. Repse, Dr. A. Tomazic; Department of Surgery, University Clinical Centre Schleswig-Holstein, Lübeck, Germany, Prof. H.-W. Bruch, PD Dr. Dr. U. Roblick; Department of Surgery, University of Mannheim, Germany, Prof. S. Post, Dr. N. Aramin; Department of Surgery, Philipps-University Marburg, Marburg, Germany, Prof. M. Rothmund, Prof. D. Bartsch; Department of Surgery, Clinical Centre Grosshadern, University of Munich, Munich, Germany, Prof. K.W. Jauch, Dr. C. Bruns; Department of Surgery, Clinical Centre rechts der Isar, Prof. R. Siewert/Prof. H. Friess, PD Dr. Schuhmacher; Department of Surgery, University Medical School, Regensburg, Germany, Prof. H. J. Schlitt, Dr. J. Werner; Department of Surgery, Borgo Roma University of Verona, Verona, Italy, Prof. C. Bassi, Dr. G. Butturini; Department of Surgery, University of Wurzburg, Wurzburg, Germany; Prof. A. Thiede/Prof. C.-T. Germer, Dr. U. Steger; Department of Surgery, Helios Hospital Wuppertal, Germany, Prof. H. Zirngibl, Dr. S. Ganzera.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
HB performed the analysis, literature research and drafted the manuscript. NRR and TL performed the survey and literature search. MKD and TJ designed the study. CMS designed the study and reviewed the manuscript. MG, GB, CS, IR and MWB reviewed and contributed substantially to the manuscript. All authors read and approved the final manuscript.