Pancreatic Surgery: Improving Postoperative Outcomes

Abstract

Pancreatic surgery is complex and remains associated with a high risk of complications. A single complication may provoke a potentially lethal cascade of associated complications. Early recognition and management of complications might improve clinical outcomes. In the first parts of this thesis, efforts made to identify the best way to diagnose and treat complications after pancreatic surgery are described. Based on these findings, we designed a multimodal algorithm for early recognition and minimally invasive management of postoperative complications after pancreatic resection. This algorithm was tested in the nationwide stepped-wedge cluster randomized trial (PORSCH trial). A smartphone application was designed incorporating the algorithm, which included daily evaluation of clinical and biochemical markers. The primary outcome occurred in 8.5% in the intervention group vs. 14.0% in the control group. All individual components of the primary outcome were decreased in the intervention group: bleeding requiring intervention (5.4% vs. 5.8%); organ failure (4.5% vs. 10.3%); 90-day mortality (2.7% vs. 5.0%). We concluded that the implementation of this multimodal algorithm improved clinical outcomes compared to usual care, including an approximate 50% reduction of nationwide mortality. This thesis presents 10 years of research on pancreatic surgery. Important discoveries have been presented and clinical practice has already changed because of these findings. Traditionally, clinical assessment of your patients is the most important factor in determining whether or not to perform a (surgical) intervention. Findings in this thesis show, however, that in patients undergoing pancreatic resection, further steps in management of complications should not be delayed, even if the patient is in good clinical condition. Clinical deterioration and even mortality can be prevented by early complication management. This concept might be extrapolated to other types of major (abdominal) surgery, for example hepatectomy or esophagectomy.