BRANDON REGIONAL HEALTH CENTER; WHIPPLE S PROCEDURE AND ESOPHAGECTOMY AUDIT

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1 BRANDON REGIONAL HEALTH CENTER; WHIPPLE S PROCEDURE AND ESOPHAGECTOMY AUDIT By: Amy Cisyk Home for the Summer Program July, 2016 Brandon, Manitoba Supervisor: Dr. Marvin Goossen

2 Whipple s Procedure Audit The outline of this report follows the December 2011 Esophagectomy Audit by Robin Smith. Overview: A review was conducted of the 31 Whipple s Procedures performed at the Brandon Regional Health Centre from March 2011 July All of these surgeries were performed by Doctor Dhalla. Approximately 2/3 rds of the patients were male, with an average age of 66 years. The principle pre-surgical diagnoses were cancer of the pancreas, ampulla and/or bile duct. The average ICU stay was 5.7 days and the average total hospital stay was 28.5 days. The surgical mortality rate was 6.5% with two in hospital deaths at days 6 and 84 post-operation. Two patients currently remain in care. Mean survival times for those deceased and currently alive are 1.27 and 1.41 years respectively. Patient Demographics 64.5% male, 35.5% female Average age years Median age - 68 years Pre-Surgical Diagnosis Diagnosis Cases CA of Pancreas 10 CA of Head of Pancreas 6 CA of Bile Duct 5 CA of Pancreas + Bile Duct 5 CA of Ampulla 4 CA of Pancreas + Ampulla 1 Total 31 Page 2 of 11

3 Surgical Type and Duration Whipple s Procedure Audit Procedure N Duration (h) Estimated Blood Loss (ml) Stay in ICU Stay in Hospital Reoperation following surgery (%) Post-op mortality (days) Whipple's /4 (25.0) 897 (n=4) 6: Procedure 2 Whipple s + PEG /11 (27.3) 279 (n=3) J-tube 5: placement 2.1 Whipple s + 4* /4 (0.0) 760 (n=1) Excision of 6: Portal Vein 2 Total 6* /6 (33.3) 338 (n=2) Pancreatectomy with 7: Splenectomy 8.8 Other 7 6: /7 (42.9) 77 (n=3) * One case is included in both categories (ie. Total Pancreatectomy with Splenectomy and Segmental Excision of Portal Vein) Other category includes Whipple s Procedures with one of the following; Hartmann's procedure, resection of common hepatic duct with hepaticojejunostomy, subtotal colectomy, VAC dessing, segmental colectomywith VAC dressing, exploratory laparotomy Page 3 of 11

4 Major Surgical Complications Whipple s Procedure Audit 16/31 cases (52%) had no intra-surgical or post-surgical complications. Pre-operative complications: o None reported Intra-operative o Patient required packed cells (x4) o Hole in small bowel where stent had been placed o Marked edema requiring VAC dressing (x2) o Patient in hyper-dynamic state, possible sepsis o J-tube connected before it was fed, failed to place the flange o Tear in spleen Post-operative Complications: o Ileus o Peritonitis o Ischemic colon, ischemic omentum o JP drain leakage requiring ongoing suction and clamping o J-tube curled up and fell out dislodged leaking stomach contents into wound o Nausea requiring tube feed o Seroma (x2) o Sepsis o Liver abscesses, renal failure, respiratory failure o Gastrocutaneous fistula o Bleed Return to OR 7 cases returned to the OR for the following reasons: Redo enteroanastomosis, VAC dressing Segmental colectomy, VAC dressing (x2) Right hemicolectomy, drainage of retroperitoneum, VAC dressing. 2 nd return; high-output ileostomy with placement of retroperitoneum drain. 3 rd ; J-tube replacement Place central line Cavity lavage, hemovac drain placed. 2 nd return; removal of PEG J tube, replacement of keofeed into efferent limb with NG tube placement. 3 rd return; upper endoscopy and clippings x4 Control bleeding. 2 nd return; packing liver with loose closure 2 cases returned to the GI unit for the following reasons: GI unit for replacement of PEG J-tube Upper GI endoscopy, swab for candida Page 4 of 11

5 Whipple s Procedure Audit Admission to ICU 30 of 31 cases were admitted to ICU (97%) with an average length of stay of 5.7 days. One case showed advanced metastatic disease, and therefore the Whipple s Procedure was converted to an Exploratory Laparotomy. This patient was admitted to recovery (length of stay in ICU of zero days). Surgical Mortality 2 of the 31 cases (6.5%) died post operatively while in care, one at 6 days and the other at 84 days. Length of Hospital Stay 27 of the 31 cases were discharged from the hospital with an average length of stay of 22.5 days, ranging from 8 thru 69 days. Of the remaining 4 cases, 2 died while in care and 2 are still admitted. Page 5 of 11

Whipple s Procedure Audit Long Term Survival Patient Status Average Survival Time (yrs) Range Surviving (n=18) 1.41 57 days 3.73 yrs Deceased (n=13) 1.27 6 days 1.

27 0.26 0.22 0.16 Survival rate is based on the assumption that the absence of a death report in the patient s hospital record indicates survival.

6 Whipple s Procedure Audit Long Term Survival Patient Status Average Survival Time (yrs) Range Surviving (n=18) days 3.73 yrs Deceased (n=13) days 1.91 yrs Period in Years Deceased Surviving Survival rate is based on the assumption that the absence of a death report in the patient s hospital record indicates survival. Histopathology 10 of 31 cases had both negative margins and negative lymph nodes. One case (designated N/A in the graphs) was metastatic and therefore did not have a histopathology report. Two cases were negative for malignancy. Page 6 of 11

7 Whipple s Procedure Audit *3 case were not staged, 1 case was not sampled due to metastatic disease Page 7 of 11

8 Esophagectomy Audit The outline of this report follows the December 2011 Esophagectomy Audit by Robin Smith. Overview: A review was conducted of the 14 esophagectomies performed at the Brandon Regional Health Centre from All of these surgeries were performed by Doctors Dhalla, Carpenter, and Mohamed. The average age of the patients was at the time of surgery was 70 years, with 8/14 patients male. The principle pre-surgical diagnoses were cancer of the esophagus, cancer of the GE junction and Barrett s esophagus. Within the study group, Cancer Care data was acquired for 8 patients, with only 3 patients receiving neo-adjuvant therapy prior to their surgery. The predominant surgical method used was the Ivor-Lewis esophagectomy, followed by the transhiatal approach. With the exception of one patient (who spent 26 days in the ICU) the average ICU stay was 2.2 days. The average total hospital stay was 17.7 days. The surgical mortality rate was 7.1% with only a single 30-day mortality at 26 days. Mean survival times for those deceased and currently alive are 0.66 and 1.58 years respectively. Surgery by Surgeon Patient Demographics 57% male, 43% female Average age years Median age years Page 8 of 11

9 Esophagectomy Audit Pre-Surgical Diagnosis Diagnosis Ca of GE Junction 4 Ca of Esophagus 11 Barrett s Esophagus 6 Many cases had two diagnoses (eg. CA of Esophagus + Barrett s Esophagus) Pre-operative neo-adjuvant therapy Cancer care records were acquired for 8 of the 14 cases in this study. 3 of 8 patients received both preoperative chemotherapy and chemoradiation. The remaining 5 cases did not receive any neo-adjuvant/preoperative chemotherapy/radiation. Surgical Type and Duration Estimated Blood Loss (ml) Reoperation following surgery Post-op mortality (days) Procedure (Esophagectomy) N Duration (h) Stay in ICU Stay in Hospital Ivor-Lewis 8 5: (n=4) 2.1* (n=2) Transhiatal 2 5: (n=1) n=0 Other 4 2: (n=1) (n=1) *Average excludes the one patient who stayed 26 days in the ICU Page 9 of 11

10 Major Surgical Complications Esophagectomy Audit 7 of 14 cases had no pre, intra or post-surgical complications. Pre-operative complications: o None Intra-operative o Scoliosis o Broken rib o Aortic bleed Post-operative Complications: o Paroxysmal atrial fibrillation o Atelectasis (x2) o Febrile (x2) o Hospital acquired UTI Return to OR Two cases returned to the OR for the following reasons: Repair aortic tear, hemothorax causing tamponade Balloon dilation of pylorus valve Admission to ICU 13 of 14 cases were admitted to ICU (92%). When excluding the outlier, the average length of stay of 2.2 days. Page 10 of 11

11 Esophagectomy Audit Length of Hospital Stay & Surgical Mortality 13 of 14 cases were discharged from the hospital with an average length of stay of 17.7 days, ranging from 11 through 29 days. 1 of 14 cases (7.1%) died in the post-operative period while in care at 26 days. Long Term Survival Patient Status Average Survival Time (yrs) Range Surviving (n=11) days 3.66 yrs Deceased (n=3) days 1.28 yrs Period in Years Surviving Deceased Survival rate is based on the assumption that the absence of a death repot in the patient s hospital record indicates survival. Page 11 of 11

JOHN M UECKER, MD, FACS COMPLEX PANCREATICODUODENAL INJURIES

JOHN M UECKER, MD, FACS COMPLEX PANCREATICODUODENAL INJURIES THE PROBLEM DUODENAL / PANCREATIC INJURIES Difficult to diagnose Not very common Anatomic and physiologic challenges 90% rate of associated