Who Do We Fail to Rescue After Pancreatoduodenectomy? Outcomes Among >4000 Procedures Expose Windows of Opportunity.

Abstract

Our investigation on in-hospital mortality after 4474 pancreatoduodenectomies aimed to identify time-dependent risks as well as windows of opportunity to rescue patients from complications. Pancreatoduodenectomy is generally considered a safe procedure with a 1% to 10% perioperative mortality based on complexity and surgical volume. Yet, patients are susceptible to life-threatening complications particularly with extended resections. Recognition of distinct vulnerabilities over time while patients recover is required to permit focused monitoring, sophisticated resource allocation, and the greatest surgical safety. Patients who deceased in-hospital after pancreatoduodenectomy between 2003 and 2021 were retrieved from the institutional pancreatectomy registry and analyzed in detail with respect to their postoperative course. Among 4474 pancreatoduodenectomies, 156 patients deceased in-hospital (3.5%). When assessing root causes of mortality, we observed 3 different clusters of complications, which were postpancreatectomy-specific (51.9%), visceral vasculature-associated (25.6%), or cardiopulmonary in origin (17.9%). The median times of root cause onset in the 3 categories were postoperative day (POD) 9, POD 4.5 ( P =0.008), and POD 3 ( P <0.001), respectively. Medians of in-hospital mortality were POD 31, POD 18 ( P =0.009), and POD 8 ( P <0.001). Intervals between root cause onset and mortality varied with medians of 23 days, 11 days ( P =0.017), and 1 day ( P <0.001). The 3 categories were similarly distributed between different types of surgical complexity. Postpancreatectomy-specific complications prompt almost half of the in-hospital mortalities after pancreatoduodenectomy, with rather long intervals for interventions to prevent failure to rescue. In contrast, visceral vasculature-related events and cardiopulmonary complications dominate early in-hospital mortalities with short intervals until mortality, demanding rigorous management of such events or preoperative conditioning. These data externally validate a previous high-volume initiative and highlight distinct windows of opportunity to optimize perioperative safety.