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1 Pancreaticobiliary Surgery: General Considerations

TABLE 1.2  Classification of Surgical Complication Adopted for Pancreatic Surgery Grade Definition I

Any deviation from the normal postoperative course without pharmacologic treatment or surgical, endoscopic, and radiologic interventions. Allowed therapeutic regimens are drugs such as antiemetics, antipyretics, analgesics, diuretics, electrolytes, and physiotherapy. This grade also includes wound infections opened at the bedside Requiring pharmacologic treatment with drugs other than ones allowed for grade I complications. Blood transfusion and total parenteral nutrition a are also included

II

III

Requiring surgical, endoscopic, or radiologic intervention

IIIa IIIb

Intervention not under general anesthesia Intervention under general anesthesia

IV

Life-threatening complication (including CNS complications) b requiring 1C/ICU management

IVa IVb

Single-organ dysfunction (including dialysis)

Multiorgan dysfunction

V

Death of a patient

postpancreatectomy complications. DGE is defined by the ISGPS as vomiting requiring the initiation or continuation of nasogastric tube decompression beyond postoperative day 3, or the inability to tolerate solid oral intake by postoperative day 7. POPF is defined by the ISGPS as the collection of any measurable volume of fluid from the pancreatic resection drain, on or after postoperative day 3 with amylase content higher than threefold the upper normal serum value. Whereas previous series in the literature may have used nearly as many definitions for these complications as there were series, thereby precluding meaningful comparison, today’s pancreaticobiliary surgeon may and should profit from the ability to compare outcomes with benchmarks in literature, and to appropriately educate patients, based on commonly accepted definitions. Although DGE and POPF can and should be graded by the surgeon according to the Clavien system, these two complications—being so common in pancreaticobiliary practices— have their own ISGPS grading systems as well. Further demonstration of the importance of defining postoperative complications is provided by the experience at JHH. Of nearly 3000 PDs performed at JHH from 1970 to 2006, approximately half were performed for pancreatic adenocarcinoma. A recent analysis of these cases revealed a perioperative mortality rate of 2% and morbidity rate of 38%. The mortality rate steadily decreased from 30% in the 1970s to 1% in the 2000s, reflecting improvements in surgical care. The morbidity rate, however, increased from 30% to 45% over a similar time period, likely reflecting the improved capturing of better defined complications. As such, length of stay decreased from 16 days in the 1980s to 8 days in the 2000s. The most common three complications in this series (which predated the adoption of the ISGPS definitions) were DGE, 15%; surgical site infections, 8%; and POPF, 5%. A subsequent trial from the same institution illustrated even more explicitly the importance of defining complications, specifically illustrating the difference between the ISGPS definition and the previous Hopkins definition of POPF: The POPF rate during a 20-month accrual period for an RCT conducted in the mid-2000s was 3% and 16% for hard and soft glands, respectively, according to the JHH definition, but according to the ISGPS definition, those same rates were 200% to 300% higher, at 9% and 41% for hard and soft glands, respectively. Assessing Risk of Complications Not all patients have an equal likelihood of suffering complications. As previously noted, the clear- est example of this differential risk is the risk of POPF, which depends largely on the texture of the If the patient suffers from a complication at the time of the discharge, the suffix “d” (for disability) is added to the respective grade of complication (including resection of the pancreatic remnant). This label indicates the need for a follow-up to fully evaluate the complication Reprinted with permission from DeOliveira M, Winter JM, Schafer M, et al. Assessment of complications after pancreatic surgery: A novel grading system applied to 633 patients undergoing pancreaticoduodenectomy. Ann Surg . 2006; 244(6): 931–939. a Note regarding DGE: The insertion of a central line for total parenteral nutritionor nasojejunal tube by endoscopy is grade IIIa. However, if a central line is still in place or a feeding tube has been inserted at the time of surgery, then a total parenteral nutrition or enteral nutrition is grade II complication. b Brain hemorrhage, ischemic stroke, subarachnoidal bleeding, but excluding transient ischemic attacks. CNS, central nervous system; IC, intermediate care; ICU, intensive care unit. Suffix “d”

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