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Selective administration of prophylactic octreotide during pancreaticoduodenectomy: a clinical and cost-benefit analysis in low- and high-risk glands.

Published on Oct 1, 2007in Journal of The American College of Surgeons4.45
· DOI :10.1016/j.jamcollsurg.2007.05.011
Tsafrir Vanounou6
Estimated H-index: 6
(BIDMC: Beth Israel Deaconess Medical Center),
Wande B. Pratt17
Estimated H-index: 17
(BIDMC: Beth Israel Deaconess Medical Center)
+ 1 AuthorsCharles M. Vollmer40
Estimated H-index: 40
(BIDMC: Beth Israel Deaconess Medical Center)
Abstract
Background The efficacy of prophylactic octreotide after pancreaticoduodenectomy has been rigorously scrutinized, yet few studies have specifically illustrated its impact in patients at high risk for pancreatic fistula. Applying a previously validated clinical classification scheme (International Study Group on Pancreatic Fistula) for postoperative pancreatic fistula severity, we examined whether prophylactic octreotide could effectuate a clinical or fiscal benefit, or both, after pancreatic resection. Study Design There were 227 consecutive patients who underwent pancreaticoduodenectomy from October 2001 to January 2007. At the surgeon's discretion, prophylactic octreotide was administered intraoperatively and continued postoperatively. Clinically relevant fistulas, requiring therapeutic interventions or resulting in severe clinical sequelae, were identified, as were other complications. Through multivariate analysis, risk factors for fistula were defined as soft gland texture; small duct size; ampullary, duodenal, cystic, or islet cell pathology; and increased blood loss. Beyond a traditional review of clinical outcomes, a novel economic cost-benefit analysis of octreotide prophylaxis was performed, with concentration of impact on high-risk glands (one or more risk factors). Results Overall, 55% of patients had at least one risk factor. Clinically relevant fistulas were present in 14.9% of all patients. High-risk glands resulted in significantly worse clinical and economic outcomes compared with low-risk glands (no risk factors present). Prophylactic octreotide in low-risk glands was neither clinically effective nor cost efficient after pancreaticoduodenectomy, contributing to 781 in overspending per patient—approximately equivalent to a 7-day postoperative course of octreotide. But in patients with high-risk glands, octreotide prophylaxis was associated with a decreased incidence (20% versus 35%) and morbidity of clinically relevant fistulas. These improved clinical outcomes were associated with reduced resource use, translating to considerable cost savings (1,849) per high-risk patient. Conclusions Octreotide prophylaxis is an effective approach to mitigate the negative impact of pancreatic fistulas, but to obtain maximal clinical value and cost benefit, octreotide should be administered exclusively to patients with high-risk glands.
  • References (38)
  • Citations (42)
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References38
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#1Tsafrir Vanounou (BIDMC: Beth Israel Deaconess Medical Center)H-Index: 6
#2Wande B. Pratt (BIDMC: Beth Israel Deaconess Medical Center)H-Index: 17
Last. Mark P. Callery (BIDMC: Beth Israel Deaconess Medical Center)H-Index: 48
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Background Although clinical pathways were developed to streamline patient care cost efficiently, few have been put to rigorous financial test. This is important today, because payors demand clear solutions to the cost-quality puzzle. We describe a novel, objective, and versatile model that can evaluate and link the clinical and economic impacts of clinical pathways. Study Design Outcomes for 209 consecutive patients undergoing high-acuity surgery (pancreaticoduodenectomy), before and after path...
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#1Wande B. PrattH-Index: 17
#2Shishir K. MaithelH-Index: 38
Last. Charles M. VollmerH-Index: 40
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Pancreatic fistula is widely regarded as the most ominous of complications following pancreatic resection. Its clinical impact and sequelae have been previously described and shown to contribute to the development of other morbid complications and high rates of mortality.1–4 Despite refinements in operative technique and advancements in postoperative management, fistulas still occur with a frequency of 5% to 30%.5–12 Efforts to mitigate this problem have included technical considerations (modifi...
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#2Jordan M. Winter (Johns Hopkins University)H-Index: 36
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Mortality associated with pancreaticoduodenectomy (PD) has decreased dramatically to less than 5% over the past 2 decades in high-volume centers,1–6 but persistent high morbidity rates have remained an important concern for patients, healthcare providers, and payers. While mortality is an objective and easily quantifiable outcome parameter, morbidity is only poorly defined, and this shortcoming has severely hampered conclusive comparisons among centers and within the same institution over time.7...
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It is uncertain whether postoperative pancreatic fistulas after distal and central pancreatectomies behave similarly to those after pancreaticoduodenectomy. To date, this concept has not been validated either clinically or economically. Overall, 256 consecutive pancreatic resections from October 2001 to February 2006 (184 pancreaticoduodenectomies, 66 distal pancreatectomies, and 6 central pancreatectomies) were evaluated according to the International Study Group of Pancreatic Fistula classific...
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The first successful local resection of a periampullary tumor was performed by Dr. William Stewart Halsted in 1898.1 The patient was a 58-year-old woman with obstructive jaundice. Halsted resected a segment of the second portion of the duodenum, including the tumor, and anastomosed the duodenum end to end. He then reimplanted the bile and pancreatic ducts. The first successful regional resection for a periampullary tumor was performed by the German surgeon from Berlin, Kausch, in 1909, and repor...
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Background Postoperative pancreatic fistula (POPF) is still regarded as a major complication. The incidence of POPF varies greatly in different reports, depending on the definition applied at each surgical center. Our aim was to agree upon an objective and internationally accepted definition to allow comparison of different surgical experiences. Methods An international panel of pancreatic surgeons, working in well-known, high-volume centers, reviewed the literature on the topic and worked toget...
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Pancreatic resection is the only treatment option that can lead to a meaningful prolonged survival in pancreatic cancer and, in some instances, perhaps a potential chance for cure. With the advent of organ and function preserving procedures, its use in the treatment of chronic pancreatitis and other less common benign diseases of the pancreas is increasing. Furthermore, over the past two decades, with technical advances and centralization of care, pancreatic surgery has evolved into a safe proce...
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