Henry A. Pitt, M.D., F.A.C.S. Chief Quality Officer Temple University Health System July 23, 2018 Orlando, Florida

Transcription

1 Are All OSIs Pancreatic Fistulas? Henry A. Pitt, M.D., F.A.C.S. Chief Quality Officer Temple University Health System July 23, 2018 Orlando, Florida

2 DISCLOSURES Leader, ACS-NSQIP HPB Collaborative Hepatectomy Pancreatectomy Major Partial Whipple Distal

3 HPB Collaborative GOALS Encourage quality improvement initiatives with engagement of HPB Surgeons, Surgeon Champions and SCRs Reduce variation among hospitals and surgeons Provide a forum to share and disseminate best practices ACS AHPBA

4 Collaborative update HPB Collaborative OVERVIEW IU Comparison Operations OSIs Reports Panc fistulas Outcomes Pancreatic fistulas Organ space infections NSQIP Pancreatic fistulas ISGPF

5 Institutions HPB Collaborative PROCEDURE TARGETED Hepatectomy Pancreatectomy USA 140 Canada 9 Australia 2 Lebanon 1 Singapore 1

6 Percent Hepatectomy N=3,783 Major HPB Collaborative OPERATIONS 2017 Partial Pancreatectomy N=5,693 Whipple Distal

7 HPB Collaborative 2017 HEPATECTOMY 2017 PANCREATECTOMY Major Hepatectomy 12 Outcomes Bile leak Liver failure Partial Hepatectomy 12 Outcomes Bile Leak Whipple Procedure 16 Outcomes Panc fistula DGE Distal Pancreatectomy 11 Outcomes Panc fistula 85 hospitals 84% cases 92 hospitals 85% cases

8 Percent Hepatectomy HPB Collaborative MORBIDITY Pancreatectomy 0 Major Partial 0 Whipple Distal

9 Percent Hepatectomy HPB Collaborative OVERALL SSI Pancreatectomy 0 Major Partial 0 Whipple Distal

10 Percent Hepatectomy HPB Collaborative SSI TYPES Pancreatectomy 0 Super ficial Organ Space 0 Super ficial Organ Space

11 HPB Collaborative LEAKS & FISTULAS 2017 Bile Leaks International Study Group Grades A, B, C Major 12% Partial 5% Pancreatic fistulas International Study Group Grades A, B, C Whipple 17% Distal 21% Bile leak Pancreatic fistula

12 OSI Pancreatic Fistula ORGAN SPACE INFECTION Before 2014 in ACS-NSQIP pancreatic fistula was not monitored Superficial SSI Deep SSI Organ Space Infection OSI 10-11% after pancreatectomy with no change CDC/NSQIP SSI

13 OSI Pancreatic Fistula PANCREATIC FISTULA ISGPF 2004 Grade A common, no clinical impact Grade B less common, delays discharge Grade C least common, serious impact Grade B+C=10-14% Clinically relevant (CR) Achilles heel Panc Fistula Achilles Heel

14 OSI Pancreatic Fistula METHODS pancreatic resection patients were monitored via ACS-NSQIP at Indiana University Hospital 250 patients randomly chosen for further analysis OSI data gathered prospectively by trained Surgical Clinical Reviewer Data on pancreatic fistulas and other intraabdominal complications determined retrospectively by careful chart review

15 20 OSI Pancreatic Fistula OSI AND LEAKS 15 % Patients OSI Bile Leaks GI Leaks

16 OSI Pancreatic Fistula PANCREATIC FISTULAS % Patients Type A Type B Type C

17 OSI Pancreatic Fistula OVERLAP

18 OSI Pancreatic Fistula CONCLUSIONS The sensitivity (55%) and specificity (45%) of Organ Space Infection (OSI) in ACS-NSQIP are too low for OSI to be a surrogate for clinically relevant postoperative pancreatic fistulas (CR-POPF) Procedure-specific variables will be required for ACS-NSQIP to improve outcomes following pancreatectomy *Parikh J, et al. JACS 2014; 219:

19 HPB Collaborative PANCREATIC FISTULA NSQIP* Grade A Whipple (17.2%) Distal (20.6%) Drain > 7d 53% 68% Grades B+C Perc drainage 30% 26% NPO/TPN 8% 2% Reoperation 6% 2% Spont drainage 3% 2% *2017 C if also died

20 Grade A HPB Collaborative PANCREATIC FISTULA NSQIP Whipple (NSQIP) Whipple (Modified)* Drain > 7d 53% 30% Grades B+C Perc drainage 30% 30% Drain > 21d 23% NPO/TPN 8% 8% Reoperation 6% 6% Spont drainage 3% 3% *Kantor et al. J Am Coll Surg 2017; 224: OSI, Sepsis, Shock, Readmission

21 HPB Collaborative PANCREATIC FISTULA NSQIP Grade A eliminated = Biochemical Leak Grade C PLUS at least one Return to the OR Organ failure Death Grade B on or after POD #3 drain amylase > 3 times upper limit serum amylase PLUS at least one Drain > 21 days IR repositioning of operative drain Percutaneous or endoscopic fluid drainage Angiography or transfusion for bleeding Signs of infection (WBC, fever) requiring antibiotics NPO + EN or TPN

22 HPB Collaborative CONCLUSIONS Whipple superficial SSIs have decreased from 10% to 7% Whipple OSIs have increased from 11% to 14% Only 55% of OSIs are CR-POPFs Whipple pancreatic fistulas (Grades A, B, C) have decreased from 18.5% to 17.2% ISGPF and NSQIP pancreatic fistula definitions have changed ISGPF and NSQIP pancreatic fistula definitions are now harmonized