Taking Theory to Practice: Quality Improvement for Pancreaticoduodenectomy and Development and Integration of the Fistula Risk Score

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BACKGROUND: Improvements in surgical outcomes are predicated on recognizing effective practices with subsequent adaptation. It is unknown whether risk assessment for pancreatic fistula (clinically relevant postoperative pancreatic fistula [CR-POPF]) after pancreaticoduodenectomy (PD) translates to improved patient outcomes at the practice level. STUDY DESIGN: A prospectively collected, single-surgeon career experience (2003 to 2018) of 455 consecutive pancreatectomies (303 PDs and 152 distal pancreatectomies) was examined. Analysis occurred during 4 eras of practice: learning curve for PD (n = 50); development of the Fistula Risk Score (n = 48); reactive, data-driven adjustments of anastomotic stent use (n = 94); and omission of prophylactic octreotide with adoption of selective drainage (n = 111). Observed to expected ratios of CR-POPF were calculated using a multi-institutional derivation set (5,379 PDs). RESULTS: After adjustment for increasing fistula risk across the 4 eras (p = 0.016), the risk-adjusted CR-POPF rate declined significantly (observed to expected ratio 1.42→1.28→1.01→0.30; p < 0.001). Literature-driven changes in fistula mitigation strategies likewise led to reductions in the overall complication burden (Postoperative Morbidity Index: 0.20→0.24→0.25→0.15; p = 0.015) and resource use (therapeutic antibiotics: p = 0.019; hospital readmission: p = 0.006; postoperative transfusion: p = 0.007). In contrast, the CR-POPF rate after distal pancreatectomy, for which no validated risk-adjustment process exists, did not vary (approximately 12%; p = 0.878). CONCLUSIONS: Patient outcomes for PD can be optimized by risk-adjusted evaluation and deliberate modification of practice.