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Changing Indications, Older Patients, and Decreasing Length of Hospitalization

James H. Balcom IV, MD; David W. Rattner, MD; Andrew L. Warshaw, MD; Yuchiao Chang, PhD; Carlos Fernandez-del Castillo, MD

Arch Surg. 2001;136:391-398.

Hypothesis  Experience with pancreatic resection for the last 10 years has resulted in new trends in patient characteristics and, for pancreaticoduodenectomy (PD), a decrease in the length of stay (LOS). This decrease is due in part to the implementation of case management and clinical pathways.

Design  Retrospective case series of patients undergoing pancreatic resection.

Setting  A university-affiliated, tertiary care referral center.

Patients  The study comprised 733 consecutive patients undergoing pancreatic resection for benign or malignant disease at the Massachusetts General Hospital in Boston from April 1990 to March 2000.

Interventions  Of the 733 pancreatic resections, 489 were PD; 190, distal pancreatectomy; 40, total pancreatectomy; and 14, middle-segment pancreatectomy.

Main Outcome Measures  Length of stay; occurrence of delayed gastric emptying, pancreatic fistula, reoperation, readmission, or other complications; mortality; and comparison of patients in 3 periods according to the implementation of case management (July 1995) and clinical pathways (September 1998).

Results  For PD, patients in group 1 (April 1990 to June 1995) were significantly younger (mean ± SD, 57 ± 15 years) than those in group 2 (July 1995 to August 1998; mean ± SD, 62 ± 13 years) and group 3 (September 1998 to October 2000; mean ± SD, 65 ± 13 years)(P <.01). Over time, the proportion of PD for cystic tumors increased from 9.9% to 20% (P = .01), and the proportion of PD for chronic pancreatitis decreased from 23% to 10% (P <.01). Use of pylorus-preserving PD decreased from 45% to 0% (P <.001). Delayed gastric emptying decreased from 17% to 6.1% (P <.01). Pancreatic fistula, reoperation, and mortality were unchanged. Length of stay for PD decreased from 16.1 ± 0.6 to 9.5 ± 0.4 days (mean ± SE) (P <.001). Multivariate analysis showed that period, case volume, pylorus-preserving PD, and presence of complications are all independent predictors of LOS (P <.05 for all). For distal pancreatectomy, patients in groups 2 and 3 were older than those in group 1 (mean ± SD, 57 ±14 vs 52 ± 17 years) (P <.05). Resections for cystic tumors increased from 26% to 52% (P <.05), and resections for chronic pancreatitis decreased from 32% to 14% (P = .06). Median LOS decreased from 9 days to 6. For total pancreatectomy, resections for cystic tumors increased from 18% to 43%. Median LOS decreased from 14.5 days to 11. For all resections, case volume increased from 4 resections per month in 1990 to 5.8 in 1995 and 12 in 2000 (r = 0.83; P <.001).

Conclusions  Older patients are increasingly being selected for pancreatic resection. This reflects an increasing frequency of operations performed for cystic tumors and fewer for chronic pancreatitis. With the exception of delayed gastric emptying, complications and mortality have remained the same or decreased slightly during the past 10 years. However, there has been a significant decrease in LOS; this is the result of implementation of case management and clinical pathways, increasing case volume, decreasing incidence of delayed gastric emptying, and decreasing use of pylorus-preserving PD.

From the Department of Surgery (Drs Balcom, Rattner, Warshaw, and Fernandez-del Castillo) and the Medical Practices Evaluation Center (Dr Chang), Massachusetts General Hospital and Harvard Medical School, Boston.

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