Quality Improvement
Thomas L. Sutton, MD
Resident
Oregon Health and Science University
Portland, Oregon, United States
Disclosure: I do not have any relevant financial / non-financial relationships with any proprietary interests.
Patients undergoing pancreaticoduodenectomy are at high risk of surgical site infections (SSIs) due to violation of the biliary and upper gastrointestinal tracts. Multiple perioperative interventions have been proposed to reduce SSIs in patients undergoing pancreaticoduodenectomy.
Methods:
In July 2017 a multidisciplinary perioperative bundle was implemented at our center aimed at enhancing recovery and reducing SSIs. Interventions included pre-habilitation, pre-operative nutritional supplementation, routine use of wound protectors and closure trays, and utilization of multimodal pain control.
Using prospective National Surgical Quality Improvement Project (NSQIP) data, patients undergoing pancreaticoduodenectomy from July 2013 to April 2020 were identified. Multivariable logistic and linear regression were utilized to generate odds ratios (OR) for experiencing the primary outcomes of interest, NSQIP-defined incisional SSIs and length of stay (LOS).
Results:
Four-hundred-fifty-seven patients underwent pancreaticoduodenectomy during the study period, with 228 (49.9%) receiving the perioperative bundle. Groups were not significantly different in most clinicopathologic characteristics (Table). Following adoption of the bundle, the proportion of patients developing NSQIP-defined incisional SSIs declined from 23.1% (n=53) to 8.8% (n=20; P < 0.001).
On multivariable analysis controlling for age, comorbidities, blood loss, and neoadjuvant therapy, bundle implementation was independently associated with reduced odds of incisional SSI (OR 0.31; 95% CI 0.18-0.54; P < 0.001). LOS was also significantly reduced following implementation (median 10 versus 11 days), with bundle implementation remaining independently associated with reduced LOS on multivariable regression (size of effect: -2.05 days; 95% CI -3.56, -0.55; P=0.008).
Conclusions:
I
In a pre-post intervention analysis utilizing standardized NSQIP definitions, implementation of a comprehensive perioperative bundle reduced incisional surgical site infections and LOS in patients undergoing pancreaticoduodenectomy.