The Beneficial Effects of Minimizing Blood Loss in Pancreatoduodenectomy

Thomas F. Seykora; Brett L. Ecker; Matthew T. McMillan; Laura Maggino; Joal D. Beane; Zhi Ven Fong; Robert H. Hollis; Nigel B. Jamieson; Ammar A. Javed; Stacy J. Kowalsky; John W. Kunstman; Giuseppe Malleo; Katherine E. Poruk; Kevin Soares; Vicente Valero; Lavanniya K.P. Velu; Ammara A. Watkins; Charles M. Vollmer; Ronald R. Salem; William E. Fisher; Mark P. Callery; Tara S. Kent; Michael G. House; Adam C. Berger; Christopher L. Wolfgang; Carlos Fernandez Del Castillo; Horacio J. Asbun; John A. Stauffer; Mark Bloomston; Ericka Haverick; Carl R. Schmidt; John D. Christein; Chad G. Ball; Elijah Dixon; Steven J. Hughes; Jeffrey A. Drebin; Michael Sprys; Amer H. Zureikat; Stephen W. Behrman; Claudio Bassi; Euan J. Dickson

doi:10.1097/SLA.0000000000002714

The Beneficial Effects of Minimizing Blood Loss in Pancreatoduodenectomy

Thomas F. Seykora, Brett L. Ecker, Matthew T. McMillan, Laura Maggino, Joal D. Beane, Zhi Ven Fong, Robert H. Hollis, Nigel B. Jamieson, Ammar A. Javed, Stacy J. Kowalsky, John W. Kunstman, Giuseppe Malleo, Katherine E. Poruk, Kevin Soares, Vicente Valero, Lavanniya K.P. Velu, Ammara A. Watkins, Charles M. Vollmer, Ronald R. Salem, William E. FisherMark P. Callery, Tara S. Kent, Michael G. House, Adam C. Berger, Christopher L. Wolfgang, Carlos Fernandez Del Castillo, Horacio J. Asbun, John A. Stauffer, Mark Bloomston, Ericka Haverick, Carl R. Schmidt, John D. Christein, Chad G. Ball, Elijah Dixon, Steven J. Hughes, Jeffrey A. Drebin, Michael Sprys, Amer H. Zureikat, Stephen W. Behrman, Claudio Bassi, Euan J. Dickson

School of Medicine

Research output: Contribution to journal › Article › peer-review

17 Scopus citations

Abstract

Objective:The aim of this study was to elucidate the impact of intraoperative blood loss on outcomes following pancreatoduodenectomy (PD).Background:The negative impact of intraoperative blood loss on outcomes in PD has long been suspected but not well characterized, particularly those factors that may be within surgeons' control.Methods:From 2001 to 2015, 5323 PDs were performed by 62 surgeons from 17 institutions. Estimated blood loss (EBL) was discretized (0 to 300, 301 to 750, 751 to 1300, and >1300 mL) using optimal scaling methodology. Multivariable regression, adjusted for patient, surgeon, and institutional variables, was used to identify associations between EBL and perioperative outcomes. Factors associated with both increased and decreased EBL were elucidated. The relative impact of surgeon-modifiable contributors was estimated through beta coefficient standardization.Results:The median EBL of the series was 400 mL [interquartile range (IQR) 250 to 600]. Intra-, post-, and perioperative transfusion rates were 15.8%, 24.8%, and 37.2%, respectively. Progressive EBL zones correlated with intra- but not postoperative transfusion in a dose-dependent fashion (P < 0.001), with a key threshold of 750 mL EBL (8.14% vs 40.9%; P < 0.001). Increasing blood loss significantly correlated with poor perioperative outcomes. Factors associated with increased EBL were trans-anastomotic stent placement, neoadjuvant chemotherapy, pancreaticogastrostomy reconstruction, multiorgan or vascular resection, and elevated operative time, of which 38.7% of the relative impact was "potentially modifiable" by the surgeon. Conversely, female sex, small duct, soft gland, minimally invasive approach, pylorus-preservation, biological sealant use, and institutional volume (≥67/year) were associated with decreased EBL, of which 13.6% was potentially under the surgeon's influence.Conclusion:Minimizing blood loss contributes to fewer intraoperative transfusions and better perioperative outcomes for PD. Improvements might be achieved by targeting modifiable factors that influence EBL.

Original language	English (US)
Pages (from-to)	147-157
Number of pages	11
Journal	Annals of surgery
Volume	270
Issue number	1
DOIs	https://doi.org/10.1097/SLA.0000000000002714
State	Published - Jul 1 2019

Keywords

blood loss
complication
outcome
pancreatectomy
pancreatoduodenectomy
risk mitigation
risk reduction
transfusion

ASJC Scopus subject areas

Surgery

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10.1097/SLA.0000000000002714

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Seykora, T. F., Ecker, B. L., McMillan, M. T., Maggino, L., Beane, J. D., Fong, Z. V., Hollis, R. H., Jamieson, N. B., Javed, A. A., Kowalsky, S. J., Kunstman, J. W., Malleo, G., Poruk, K. E., Soares, K., Valero, V., Velu, L. K. P., Watkins, A. A., Vollmer, C. M., Salem, R. R., ... Dickson, E. J. (2019). The Beneficial Effects of Minimizing Blood Loss in Pancreatoduodenectomy. Annals of surgery, 270(1), 147-157. https://doi.org/10.1097/SLA.0000000000002714

Seykora, TF, Ecker, BL, McMillan, MT, Maggino, L, Beane, JD, Fong, ZV, Hollis, RH, Jamieson, NB, Javed, AA, Kowalsky, SJ, Kunstman, JW, Malleo, G, Poruk, KE, Soares, K, Valero, V, Velu, LKP, Watkins, AA, Vollmer, CM, Salem, RR, Fisher, WE, Callery, MP, Kent, TS, House, MG, Berger, AC, Wolfgang, CL, Castillo, CFD, Asbun, HJ, Stauffer, JA, Bloomston, M, Haverick, E, Schmidt, CR, Christein, JD, Ball, CG, Dixon, E, Hughes, SJ, Drebin, JA, Sprys, M, Zureikat, AH, Behrman, SW, Bassi, C & Dickson, EJ 2019, 'The Beneficial Effects of Minimizing Blood Loss in Pancreatoduodenectomy', Annals of surgery, vol. 270, no. 1, pp. 147-157. https://doi.org/10.1097/SLA.0000000000002714

@article{ea33eafdd0ba4943a159588ea7d11dc5,

title = "The Beneficial Effects of Minimizing Blood Loss in Pancreatoduodenectomy",

abstract = "Objective:The aim of this study was to elucidate the impact of intraoperative blood loss on outcomes following pancreatoduodenectomy (PD).Background:The negative impact of intraoperative blood loss on outcomes in PD has long been suspected but not well characterized, particularly those factors that may be within surgeons' control.Methods:From 2001 to 2015, 5323 PDs were performed by 62 surgeons from 17 institutions. Estimated blood loss (EBL) was discretized (0 to 300, 301 to 750, 751 to 1300, and >1300 mL) using optimal scaling methodology. Multivariable regression, adjusted for patient, surgeon, and institutional variables, was used to identify associations between EBL and perioperative outcomes. Factors associated with both increased and decreased EBL were elucidated. The relative impact of surgeon-modifiable contributors was estimated through beta coefficient standardization.Results:The median EBL of the series was 400 mL [interquartile range (IQR) 250 to 600]. Intra-, post-, and perioperative transfusion rates were 15.8%, 24.8%, and 37.2%, respectively. Progressive EBL zones correlated with intra- but not postoperative transfusion in a dose-dependent fashion (P < 0.001), with a key threshold of 750 mL EBL (8.14% vs 40.9%; P < 0.001). Increasing blood loss significantly correlated with poor perioperative outcomes. Factors associated with increased EBL were trans-anastomotic stent placement, neoadjuvant chemotherapy, pancreaticogastrostomy reconstruction, multiorgan or vascular resection, and elevated operative time, of which 38.7% of the relative impact was {"}potentially modifiable{"} by the surgeon. Conversely, female sex, small duct, soft gland, minimally invasive approach, pylorus-preservation, biological sealant use, and institutional volume (≥67/year) were associated with decreased EBL, of which 13.6% was potentially under the surgeon's influence.Conclusion:Minimizing blood loss contributes to fewer intraoperative transfusions and better perioperative outcomes for PD. Improvements might be achieved by targeting modifiable factors that influence EBL.",

keywords = "blood loss, complication, outcome, pancreatectomy, pancreatoduodenectomy, risk mitigation, risk reduction, transfusion",

author = "Seykora, {Thomas F.} and Ecker, {Brett L.} and McMillan, {Matthew T.} and Laura Maggino and Beane, {Joal D.} and Fong, {Zhi Ven} and Hollis, {Robert H.} and Jamieson, {Nigel B.} and Javed, {Ammar A.} and Kowalsky, {Stacy J.} and Kunstman, {John W.} and Giuseppe Malleo and Poruk, {Katherine E.} and Kevin Soares and Vicente Valero and Velu, {Lavanniya K.P.} and Watkins, {Ammara A.} and Vollmer, {Charles M.} and Salem, {Ronald R.} and Fisher, {William E.} and Callery, {Mark P.} and Kent, {Tara S.} and House, {Michael G.} and Berger, {Adam C.} and Wolfgang, {Christopher L.} and Castillo, {Carlos Fernandez Del} and Asbun, {Horacio J.} and Stauffer, {John A.} and Mark Bloomston and Ericka Haverick and Schmidt, {Carl R.} and Christein, {John D.} and Ball, {Chad G.} and Elijah Dixon and Hughes, {Steven J.} and Drebin, {Jeffrey A.} and Michael Sprys and Zureikat, {Amer H.} and Behrman, {Stephen W.} and Claudio Bassi and Dickson, {Euan J.}",

note = "Funding Information: We would like to recognize the following members of the Pancreas Fistula Study Group and their respective institutions for their leadership and noteworthy contributions to this manuscript Publisher Copyright: {\textcopyright} 2018 Wolters Kluwer Health, Inc. All rights reserved.",

year = "2019",

month = jul,

day = "1",

doi = "10.1097/SLA.0000000000002714",

language = "English (US)",

volume = "270",

pages = "147--157",

journal = "Annals of surgery",

issn = "0003-4932",

publisher = "Lippincott Williams and Wilkins",

number = "1",

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TY - JOUR

T1 - The Beneficial Effects of Minimizing Blood Loss in Pancreatoduodenectomy

AU - Seykora, Thomas F.

AU - Ecker, Brett L.

AU - McMillan, Matthew T.

AU - Maggino, Laura

AU - Beane, Joal D.

AU - Fong, Zhi Ven

AU - Hollis, Robert H.

AU - Jamieson, Nigel B.

AU - Javed, Ammar A.

AU - Kowalsky, Stacy J.

AU - Kunstman, John W.

AU - Malleo, Giuseppe

AU - Poruk, Katherine E.

AU - Soares, Kevin

AU - Valero, Vicente

AU - Velu, Lavanniya K.P.

AU - Watkins, Ammara A.

AU - Vollmer, Charles M.

AU - Salem, Ronald R.

AU - Fisher, William E.

AU - Callery, Mark P.

AU - Kent, Tara S.

AU - House, Michael G.

AU - Berger, Adam C.

AU - Wolfgang, Christopher L.

AU - Castillo, Carlos Fernandez Del

AU - Asbun, Horacio J.

AU - Stauffer, John A.

AU - Bloomston, Mark

AU - Haverick, Ericka

AU - Schmidt, Carl R.

AU - Christein, John D.

AU - Ball, Chad G.

AU - Dixon, Elijah

AU - Hughes, Steven J.

AU - Drebin, Jeffrey A.

AU - Sprys, Michael

AU - Zureikat, Amer H.

AU - Behrman, Stephen W.

AU - Bassi, Claudio

AU - Dickson, Euan J.

N1 - Funding Information: We would like to recognize the following members of the Pancreas Fistula Study Group and their respective institutions for their leadership and noteworthy contributions to this manuscript Publisher Copyright: © 2018 Wolters Kluwer Health, Inc. All rights reserved.

PY - 2019/7/1

Y1 - 2019/7/1

N2 - Objective:The aim of this study was to elucidate the impact of intraoperative blood loss on outcomes following pancreatoduodenectomy (PD).Background:The negative impact of intraoperative blood loss on outcomes in PD has long been suspected but not well characterized, particularly those factors that may be within surgeons' control.Methods:From 2001 to 2015, 5323 PDs were performed by 62 surgeons from 17 institutions. Estimated blood loss (EBL) was discretized (0 to 300, 301 to 750, 751 to 1300, and >1300 mL) using optimal scaling methodology. Multivariable regression, adjusted for patient, surgeon, and institutional variables, was used to identify associations between EBL and perioperative outcomes. Factors associated with both increased and decreased EBL were elucidated. The relative impact of surgeon-modifiable contributors was estimated through beta coefficient standardization.Results:The median EBL of the series was 400 mL [interquartile range (IQR) 250 to 600]. Intra-, post-, and perioperative transfusion rates were 15.8%, 24.8%, and 37.2%, respectively. Progressive EBL zones correlated with intra- but not postoperative transfusion in a dose-dependent fashion (P < 0.001), with a key threshold of 750 mL EBL (8.14% vs 40.9%; P < 0.001). Increasing blood loss significantly correlated with poor perioperative outcomes. Factors associated with increased EBL were trans-anastomotic stent placement, neoadjuvant chemotherapy, pancreaticogastrostomy reconstruction, multiorgan or vascular resection, and elevated operative time, of which 38.7% of the relative impact was "potentially modifiable" by the surgeon. Conversely, female sex, small duct, soft gland, minimally invasive approach, pylorus-preservation, biological sealant use, and institutional volume (≥67/year) were associated with decreased EBL, of which 13.6% was potentially under the surgeon's influence.Conclusion:Minimizing blood loss contributes to fewer intraoperative transfusions and better perioperative outcomes for PD. Improvements might be achieved by targeting modifiable factors that influence EBL.

AB - Objective:The aim of this study was to elucidate the impact of intraoperative blood loss on outcomes following pancreatoduodenectomy (PD).Background:The negative impact of intraoperative blood loss on outcomes in PD has long been suspected but not well characterized, particularly those factors that may be within surgeons' control.Methods:From 2001 to 2015, 5323 PDs were performed by 62 surgeons from 17 institutions. Estimated blood loss (EBL) was discretized (0 to 300, 301 to 750, 751 to 1300, and >1300 mL) using optimal scaling methodology. Multivariable regression, adjusted for patient, surgeon, and institutional variables, was used to identify associations between EBL and perioperative outcomes. Factors associated with both increased and decreased EBL were elucidated. The relative impact of surgeon-modifiable contributors was estimated through beta coefficient standardization.Results:The median EBL of the series was 400 mL [interquartile range (IQR) 250 to 600]. Intra-, post-, and perioperative transfusion rates were 15.8%, 24.8%, and 37.2%, respectively. Progressive EBL zones correlated with intra- but not postoperative transfusion in a dose-dependent fashion (P < 0.001), with a key threshold of 750 mL EBL (8.14% vs 40.9%; P < 0.001). Increasing blood loss significantly correlated with poor perioperative outcomes. Factors associated with increased EBL were trans-anastomotic stent placement, neoadjuvant chemotherapy, pancreaticogastrostomy reconstruction, multiorgan or vascular resection, and elevated operative time, of which 38.7% of the relative impact was "potentially modifiable" by the surgeon. Conversely, female sex, small duct, soft gland, minimally invasive approach, pylorus-preservation, biological sealant use, and institutional volume (≥67/year) were associated with decreased EBL, of which 13.6% was potentially under the surgeon's influence.Conclusion:Minimizing blood loss contributes to fewer intraoperative transfusions and better perioperative outcomes for PD. Improvements might be achieved by targeting modifiable factors that influence EBL.

KW - blood loss

KW - complication

KW - outcome

KW - pancreatectomy

KW - pancreatoduodenectomy

KW - risk mitigation

KW - risk reduction

KW - transfusion

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The Beneficial Effects of Minimizing Blood Loss in Pancreatoduodenectomy

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