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Benchmarks in Pancreatic Surgery

A Novel Tool for Unbiased Outcome Comparisons

Sánchez-Velázquez, Patricia MD, PhD*; Muller, Xavier MD*; Malleo, Giuseppe MD; Park, Joon-Seong MD, PhD; Hwang, Ho-Kyoung MD, PhD; Napoli, Niccolò MD§; Javed, Ammar A. MD; Inoue, Yosuke MD, PhD||; Beghdadi, Nassiba MD**; Kalisvaart, Marit MD††; Vigia, Emanuel MD‡‡; Walsh, Carrie D. BA§§; Lovasik, Brendan MD¶¶; Busquets, Juli MD, PhD||||; Scandavini, Chiara MD***; Robin, Fabien MD†††; Yoshitomi, Hideyuki MD, PhD‡‡‡; Mackay, Tara M. MD§§§; Busch, Olivier R. MD§§§; Hartog, Hermien MD, PhD¶¶¶; Heinrich, Stefan MD||||||; Gleisner, Ana MD, PhD****; Perinel, Julie MD††††; Passeri, Michael MD‡‡‡‡; Lluis, Nuria MD§§§§; Raptis, Dimitri A MD, PhD*; Tschuor, Christoph MD, PhD*; Oberkofler, Christian E. MD*; DeOliveira, Michelle L. MD, PhD*; Petrowsky, Henrik MD*; Martinie, John MD‡‡‡‡; Asbun, Horacio MD§§§§; Adham, Mustapha MD††††; Schulick, Richard MD****; Lang, Hauke MD||||||; Koerkamp, Bas Groot MD, PhD¶¶¶; Besselink, Marc G. MD, PhD§§§; Han, Ho-Seong MD, PhD¶¶¶¶; Miyazaki, Masaru MD||||||||; Ferrone, Cristina R. MD*****; Fernández-del Castillo, Carlos MD*****; Lillemoe, Keith D. MD*****; Sulpice, Laurent MD, PhD†††; Boudjema, Karim MD, PhD†††; Del Chiaro, Marco MD, PhD***; Fabregat, Joan MD, PhD||||; Kooby, David A. MD¶¶; Allen, Peter MD†††††; Lavu, Harish MD§§; Yeo, Charles J. MD§§; Barroso, Eduardo MD‡‡; Roberts, Keith MD, PhD††; Muiesan, Paolo MD, PhD††; Sauvanet, Alain MD, PhD**; Saiura, Akio MD, PhD||; Wolfgang, Christopher L. MD, PhD; Cameron, John L. MD, PhD; Boggi, Ugo MD§; Yoon, Dong-Sup MD, PhD; Bassi, Claudio MD; Puhan, Milo A. MD, PhD‡‡‡‡‡; Clavien, Pierre-Alain MD, PhD*

doi: 10.1097/SLA.0000000000003223
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Objective: To use the concept of benchmarking to establish robust and standardized outcome references after pancreatico-duodenectomy (PD).

Background: Best achievable results after PD are unknown. Consequently, outcome comparisons among different cohorts, centers or with novel surgical techniques remain speculative.

Methods: This multicenter study analyzes consecutive patients (2012–2015) undergoing PD in 23 international expert centers in pancreas surgery. Outcomes in patients without significant comorbidities and major vascular resection (benchmark cases) were analyzed to establish 20 outcome benchmarks for PD. These benchmarks were tested in a cohort with a poorer preoperative physical status (ASA class ≥3) and a cohort treated by minimally invasive approaches.

Results: Two thousand three hundred seventy-five (38%) low-risk cases out of a total of 6186 PDs were analyzed, disclosing low in-hospital mortality (≤1.6%) but high morbidity, with a 73% benchmark morbidity rate cumulated within 6 months following surgery. Benchmark cutoffs for pancreatic fistulas (B-C), severe complications (≥ grade 3), and failure-to-rescue rate were 19%, 30%, and 9%, respectively. The ASA ≥3 cohort showed comparable morbidity but a higher in hospital-mortality (3% vs 1.6%) and failure-to-rescue rate (16% vs 9%) than the benchmarks. The proportion of benchmark cases performed varied greatly across centers and continents for both open (9%–93%) and minimally invasive (11%–62%) PD. Centers operating mostly on complex PD cases disclosed better results than those with a majority of low-risk cases.

Conclusion: The proposed outcome benchmarks for PD, established in a large-scale international patient cohort and tested in 2 different cohorts, may allow for meaningful comparisons between different patient cohorts, centers, countries, and surgical techniques.

*Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland

Department of Surgery, University Hospital of Verona, “Pancreas Institute,” Verona, Italy

Department of Surgery, Yonsei Severance Hospital, Seoul, South Korea

§Division of General and Transplant Surgery, University of Pisa, Pisa, Italy

The John L. Cameron Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD

||Department of Surgery, Cancer Institute Hospital, Tokyo, Japan

**Department of Surgery, Hôpital Beaujon, Clichy, France

††Department of Surgery, Queen Elizabeth Hospital, Birmingham, UK

‡‡Department of Surgery, Curry Cabral Hospital, CHLC, Lisboa, Portugal

§§Department of Surgery, Thomas Jefferson University, Philadelphia, PA

¶¶Department of Surgery, Emory University School of Medicine, Atlanta, GA

||||Department of Surgery, University Hospital of Bellvitge, Barcelona, Spain

***Department of Surgery, Karolinska University Hospital, Stockholm, Sweden

†††Department of Digestive Surgery, E Herriot University Hospital, HCL, UCBL1, Lyon, France

‡‡‡Department of General Surgery, Chiba University Hospital, Chiba Japan

§§§Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands

¶¶¶Department of Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands

||||||Department of Surgery, University Hospital of Mainz, Mainz, Germany

****Department of Surgery, University of Colorado, Denver, CO

††††Department of Surgery, E Herriot University Hospital, HCL, Lyon, France

‡‡‡‡Department of Surgery, Carolina's Health Care Hospital, NC

§§§§Department of Surgical Oncology Miami Cancer Institute, Miami, FL

¶¶¶¶Department of Surgery, Seoul National University Bundang Hospital, Seoul, South Korea

||||||||Department of Surgery, International University of Health and Welfare, Mita Hospital, Tokyo, Japan

*****Department of Surgery, Massachusetts General Hospital, Boston, MA

†††††Department of Surgery, Memorial Sloan-Kettering Cancer Center (MSKCC), New York, NY

‡‡‡‡‡Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland.

Reprints: Pierre-Alain Clavien, MD, PhD, Department of Surgery and Transplantation, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland. E-mail: clavien@access.uzh.ch.

All authors approved the final manuscript.

P.S. and X.M. contributed equally as first authors.

The authors report no conflicts of interest.

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