Timing of elective surgery as a perioperative outcome variable: analysis of pancreaticoduodenectomy

Abstract

Objectives: The timing of major elective operations is a potentially important but rarely examined outcome variable. This study examined elective pancreaticoduodenectomy (PD) timing as a perioperative outcome variable.

Methods: Consecutive patients submitted to PD were identified. Determinants of 90-day morbidity (prospectively graded and tracked), anastomotic leak or fistula, and mortality, including operation start time (time of day), day of week and month, were assessed in univariate and multivariate analyses. Operation start time was analysed as a continuous and a categorical variable.

Results: Of the 819 patients identified, 405 (49.5%) experienced one or more complications (total number of events = 684); 90-day mortality was 3.5%. On multivariate analysis, predictors of any morbidity included male gender (P = 0.009) and estimated blood loss (P = 0.017). Male gender (P = 0.002), benign diagnosis (P = 0.002), presence of comorbidities (P = 0.002), American Society of Anesthesiologists (ASA) score (P = 0.025), larger tumour size (P = 0.013) and positive resection margin status (P = 0.005) were associated with the occurrence of anastomotic leak or fistula. Cardiac and pulmonary comorbidities were the only variables associated with 90-day mortality. Variables pertaining to procedure scheduling were not associated with perioperative morbidity or mortality. Operation start time was not significant when analysed as a continuous or a categorical variable, or when stratified by surgeon.

Conclusions: Perioperative outcome after PD is determined by patient, disease and operative factors and does not appear to be influenced by procedure timing.

Figure 1

Distribution of 819 pancreaticoduodenectomies according to surgical scheduling in the 9-year period studied(2000–2008). (a) Distribution of operations, related postoperative complications, leaks and 90-day mortality stratified by month (P = 0.920, P = 0.715 and P = 0.736, respectively). (b) Frequency of postoperative complications, leaks and fistulae, and 90-day mortality stratifiedby day of the week (P = 0.279, P = 0.097 and P = 0.114, respectively). (c) Number of operations, associated complications, leaks or fistulae, and 90-day mortality stratified by start time (prior to or after 12.00 h) (P = 0.057, P = 0.760 and P = 0.690, respectively)

Figure 2

Perioperative outcomes of 260 pancreaticoduodenectomies with surgical start times after 12.00 h. Patients are stratified by perioperative outcomes of any complication, leaks or fistulae, mortality within 90 days, and no complications (P = 0.731, P = 0.489 and P = 0.345, respectively)