Pancreatic Fistula and Delayed Gastric Emptying Are the Highest-Impact Complications After Whipple

Background: Patients undergoing pancreaticoduodenectomy are at risk for a variety of adverse postoperative events, including generic complications such as surgical site infection (SSI) and procedure-specific complications such as postoperative pancreatic fistula (POPF) and delayed gastric emptying (DGE). Knowing which complications have the greatest effect on these patients can help to maximize the value of quality improvement resources. This study aims to quantify the effect of specific postoperative complications on clinical outcomes and resource utilization after pancreaticoduodenectomy. Materials and methods: Patients undergoing pancreaticoduodenectomy between January 2014 and December 2016, who were included in the pancreatectomy-targeted American College of Surgeons National Surgical Quality Improvement Program, were assessed for the development of specific postoperative complications, along with the contributions of these complications toward subsequent clinical outcome and resource utilization. The main outcomes were 30-d end-organ dysfunction, mortality, prolonged hospitalization, nonrounding discharge status, and hospital readmission. Risk-adjusted population attributable fractions were estimated for each complication-outcome pair, with the population attributable fraction representing the anticipated percentage reduction in the outcome where the complication was able to be completely prevented. Results: About 10,922 patients undergoing pancreaticoduodenectomy were included for analysis. The most common postoperative complications were DGE (17.3%), POPF (10.1%), incisional SSI (10.0%), and organ/space SSI (6.2%). POPF and DGE were the only complications that demonstrated sizable effects for all clinical and resource utilization outcomes studied. Other complications had sizable effects for only a few of the outcomes or had small effects for all the outcomes. Conclusions: Quality initiatives seeking to minimize the burden imposed by postpancreaticoduodenectomy morbidity should focus on POPF and DGE rather than generic complications.