Clinical Pathways For Pancreatic Surgery: Are They A Suitable Instrument For Process Standardization To Improve Process And Outcome Quality Of Patients Undergoing Distal And Total Pancreatectomy? - A Retrospective Cohort Study

Figures & data

Figure 1 Flowchart of patient recruitment. The four groups comprised all patients consecutively operated during the respective study period.

Abbreviations: Pre-CP-D Group, Pre-Clinical pathway-Distal pancreatectomy Group; CP-D Group, Clinical pathway-Distal pancreatectomy Group; Pre-CP-T Group, Pre-Clinical pathway-Total pancreatectomy Group; CP-T Group, Clinical pathway-Total pancreatectomy Group.

Table 1 Characteristics Of The Study Groups

Patient Characteristic	Distal Pancreatectomy		p-value	Total Pancreatectomy		p-value
	January 2006 -February 2015			August 2003 -February 2015
	Pre-CP-D Group (n=43) %	CP-D-Group (n=42) %		Pre-CP-T Group (n=24) %	CP-T-Group (n=19) %
Mean age (years)	63.79	62.12	0.595	66.04	66.68	0.853
Sex			0.933			0.342
Male	16 (37.2)	16 (38.1)		13 (54.2)	13 (68.4)
Female	27 (62.8)	26 (61.9)		11 (45.8)	6 (31.6)
Mean BMI	28.00	26.18	0.241	24.75	25.25	0.691
ASA-Score			0.709			0.868
I	3 (6.9)	2 (4.7)		1 (4.2)	1 (5.3)
II	17 (39.5)	22 (52.4)		7 (29.2)	9 (47.4)
III	11 (25.5)	18 (42.9)		4 (16.6)	7 (36.8)
IV	0	0		0	2 (10.5)
X	12 (28.0)	0		12 (50.0)	0
Underlying condition
Adenocarcinoma	13 (30.2)	10 (23.8)		20 (83.3)	10 (52.6)
Others	8 (18.6)	15 (35.7)		0	4 (21.1)
NET	5 (11.6)	4 (9.5)		0	0
IPMN	11 (25.6)	7 (16.7)		3 (12.5)	3 (15.8)
Chronic pancreatitis	6 (14.0)	6 (14.4)		1 (4.2)	2 (10.5)
UICC^+			0.092			0.593
IA	0	1 (2.4)		0	1 (5.3)
IB	1 (2.3)	0		1 (4.2)	0
IIA	4 (9.3)	3 (7.1)		4 (16.7)	2 (10.5)
IIB	6 (14.0)	5 (11.9)		11 (45.8)	6 (31.6)
III	0	1 (2.4)		1 (4.2)	1 (5.3)
IV	2 (4.7)	0		2 (8.3)	0
X	0	0		1 (44.2)	0
No carcinoma	28 (65.1)	32 (76.2)		4 (16.7)	9 (47.3)
Mean albumin (g/l)	36.2	36.0	0.877	34.52	32.4	0.371
Mean hemoglobin g/dl)	12.74	12.75	0.971	12.58	12.59	0.978
Median glucose (mg/dl) [range]	100 [46–251]	110.5 [9–460]	0.651	115 [74–339]	117 [69–232]	0.864
Mean operation time (min)	245.86	244.17	0.913	406.92	439.63	0.354
Splenectomy	27 (62.8)	35 (83.3)	0.033*	7 (29.1)	6 (31.6)	0.864
Median number of resected lymph node [range]	12 [1–35]	9 [0–33]	0.202	17.5 [2–39]	16.5 [6–44]	0.796
Median number transfused blood products [range]	0 [0–6]	0 [0–8]	0.295	1.5 [0–53]	1 [0–27]	0.372

Notes: Underlying condition others Pre-CP-D Group= in declining order three cystadenomas, two non-Hodgkin lymphomas, and one pancreatic adenosquamous carcinoma, perforated pancreatic cyst, biliary fistula each; dignity others CP-D Group= in declining order seven cystadenomas; and one non Hodgkin lymphoma, liposarcoma, infiltrating urothelial carcinoma; metastasis of renal cell carcinoma, pseudocyst; metastasis of bronchial carcinoma, pancreas retention cyst, intrapancreatic splenic heterotopia each; dignity others CP-T Group= in declining order two undifferentiated pancreas carcinomas, and one metastasis of liposarcoma, metastasis of renal cell carcinoma each; *p-value ≤ 0.05; ⁺for patients with pancreatic adenocarcinoma; X=missing data.

Abbreviations: BMI, Body-Mass-Index; ASA, American Society of Anesthesiology; UICC, Union Internationale Contre le Cancer; Pre-CP-D Group, Pre-Clinical pathway-Distal pancreatectomy Group; CP-D Group, Clinical pathway-Distal pancreatectomy Group; Pre-CP-T Group, Pre-Clinical pathway-Total pancreatectomy Group; CP-T Group, Clinical pathway-Total pancreatectomy Group; g/l, gram/liter; g/dl, gram/deciliter.

Table 2 Parameters Of Process Quality

Patient Characteristic	Distal Pancreatectomy		p-value	Total Pancreatectomy		p-value
	January 2006 -February 2015			August 2003 -February 2015
	Pre-CP-D Group(n=43) %	CP-D Group(n=42) %		Pre-CP-T Group(n=24) %	CP-T Group(n=19) %
Somatostatin administration (at least once)	37 (86.1)	32 (78.1)	0.339	2 (8.3)	3 (15.8)	0.64
Pancreas enzyme substitution (at least once)	17 (39.5)	5 (11.9)	0.004*	24 (100)	19 (100)	1.0
Antibiotic prophylaxis	38 (90.5)	41 (97.6)	0.36	19 (90.5)	19 (100)	0.489
Peridural analgesia	38 (90.5)	37 (88.1)	1.0	20 (83.3)	19 (100)	0.614
Central venous catheter	38 (90.5)	29 (69.1)	0.015*	23 (95.8)	19 (100)
Arterial catheter	39 (92.9)	36 (85.7)	0.483	23 (100)	19 (100)
Usage of incentive spirometer	35 (83.3)	42 (100)	0.012*	14 (58.3)	18 (94.7)	0.012*
Mean day of PDA removement	5.24	3.9	0.132	4.89	5.93	0.429
Median day of central venous catheter removement [range]	5 [1–16]	4 [0–19]	0.64	6 [4–52]	9 [4–74]	0.137
Median day of arterial catheter removement [range]	1 [0–9]	1 [0–6]	0.725	3 [0–6]	2 [2–23]	0.449
Median day of foley catheter removal [range]	3 [1–11]	3 [1–23]	0.805	5 [2–20]	6.5 [3–48]	0.066
Mean day of nasogastric tube removal	2.43	4.33	0.39	3.78	12.4	0.347
Median day of drain removal [range]	7 [5–56]	6 [4–47]	0.243	7 [4–53]	6 [2–49]	0.357
Median day of first measurement of pancreas enzymes	1 [0–3]	3 [1–5]	<0.0001*
Median day of second measurement of pancreas enzymes [range]	3 [1–8]	5 [2–14]	<0.0001*
Median day of first intake of liquids [range]	0 [0–2]	0 [0–2]	0.42	1 [0–7]	1 [0–23]	1.0
Mean day of first intake of liquid nutritional supplement	1.72	1.75	0.939	3.96	5.17	0.475
Median day of first intake of food [range]	3 [0–10]	2 [1–26]	0.266	5 [2–13]	5 [4–44]	0.787
Median day of first mobilization to edge of the bed [range]	1 [0–2]	1 [0–16]	0.062	1 [1–3]	1 [1–26]	0.839
Median day of full mobilization [range]	3 [0–5]	3 [1–17]	0.034*	3 [1–12]	3 [1–49]	0.863

Notes: *=p-value ≤ 0.05.

Abbreviations: Pre-CP-D Group, Pre-Clinical pathway-Distal pancreatectomy Group; CP-D Group, Clinical pathway-Distal pancreatectomy Group; Pre-CP-T Group, Pre-Clinical pathway-Total pancreatectomy Group; CP-T Group, Clinical pathway-Total pancreatectomy Group; PDA, peridural anesthesia.

Table 3 Parameters Of Outcome Quality

Patient Characteristic	Distal Pancreatectomy		p-value	Total Pancreatectomy		p-value
	January 2006 -February 2015			August 2003 -February 2015
	Pre- CP-D Group (n=43) %	CP-D-Group (n=42) %		Pre-CP-T Group (n=24) %	CP-T Group (n=19) %
Readmission	10 (23.3)	6 (14.3)	0.339	3 (12.5)	2 (10.5)	1.0
Mortality	1 (2.4)	1 (2.5)	1.0	5 (20.8)	3 (15.8)	1.0
Morbidity according to Clavien-Dindo classification			0.688			0.808
0	11 (25.6)	12 (28.6)		4 (16.7)	1 (5.3)
I	13 (30.2)	13 (30.9)		4 (16.7)	4 (21.0)
II	11 (25.6)	9 (21.4)		5 (20.8)	5 (26.3)
IIIA	3 (7.0)	6 (14.3)		2 (8.3)	2 (10.5)
IIIB	4 (9.3)	1 (2.4)		3 (12.5)	3 (15.8)
IVA	0	0		0	1 (5.3)
IVB	0	0		1 (4.2)	0
V	1 (2.4)	1 (2.5)		5 (20.8)	3 (15.8)
POPF			0.357
Grade A	5 (11.6)	8 (19.1)
Grade B	10 (23.3)	7 (16.7)
Grade C	1 (2.3)	4 (9.5)
DGE			0.112			0.962
Grade A	11 (25.6)	5 (11.9)		4 (16.7)	2 (10.5)
Grade B	1 (2.3)	4 (9.5)		3 (12.5)	3 (15.8)
Grade C	0	2 (4.8)		3 (12.5)	2 (10.5)
PPH			0.202			0.881
Grade A	1 (2.3)	0		1 (4.2)	2 (10.5)
Grade B	0	0		1 (4.2	1 (5.3)
Grade C	1 (2.3)	0		1 (4.2)	0
Postoperative pancreatitis	2 (4.7)	1 (2.4)	1.0
Insulin administration (at least once)	23 (56.1)	21 (50.0)	0.578	24 (100)	19 (100)	0.209
Postoperative diabetes	12 (27.9)	3 (7.1)	0.012*	24 (100)	19 (100)
Hypoglycemia	0	0		0	0
Median [range] number of days with blood glucose ≥200 mg/dl	2.5 [0–24]	0 [0–13]	0.006*	10 [3–21]	11.5 [0–29]	0.443
Exocrine insufficiency	16 (37.2)	5 (11.9)	0.007*	24 (100)	19 (100)	1.0
Revisional surgery	6 (14.0)	3 (7.1)	0.36	9 (37.5)	7 (36.8)	0.965
Median [range] number of days with highest pain level > 3	1 [0–11]	2 [0–16]	0.079	1 [0–6]	3 [0–9]	0.012*
Analgesics requested (Mean number of doses during hospital stay)	0.81	0.89	0.481	0.52	0.47	0.87
Mean day of first defecation	3.74	3.88	0.72	4.29	4.88	0.473
Discharge			1			1
Home	39 (90.7)	38 (90.5)		15 (62.5)	12 (63.2)
Other hospital	1 (2.3)	1 (2.4)		1 (4.2)	1 (5.3)
Rehabilitation	2 (4.7)	2 (4.8)		3 (12.5)	3 (15.8)
Median [range] length of stay on ICU	1 [1–11]	1.5 [1–20]	0.91	6 [2–71]	6 [2–68]	0.432
Median [range] length of stay	16 [8–66]	14 [5–77]	0.162	20 [14–75]	28 [12–140]	0.274
Median [range] length of stay postoperative	13 [7–65]	13 [4–76]	0.41	16 [13–60]	22 [11–139]	0.162

Notes: Postoperative diabetes= fasting blood glucose level higher than 126 mg/dl; Rehab=Rehabilitation; *=p-value ≤ 0.05.

Abbreviations: Pre-CP-D Group, Pre-Clinical pathway-Distal pancreatectomy Group; CP-D Group, Clinical pathway-Distal pancreatectomy Group; Pre-CP-T Group, Pre-Clinical pathway-Total pancreatectomy Group; CP-T Group, Clinical pathway-Total pancreatectomy Group; POPF, Postoperative pancreatic fistula; DGE, Delayed gastric emptying; PPH, Postoperative pancreatic hemorrhage.