Operative Time as a Measure of Quality in Pancreaticoduodenectomy: Is Faster Better? A Retrospective Review Using the ACS NSQIP Database

Abstract

Objective: To determine if pancreaticoduodenectomy operative time can provide insight into surgeon performance and thus be considered for use as a quality indicator. Background: Case volume is the traditional quality metric for complex pancreatic surgery, with studies showing better outcomes for high-volume providers. However, there are surgeons performing fewer cases with good quality who are overlooked for referrals directed to high-volume “centers of excellence”. Additional quality metrics are needed. Methods: The ACS NSQIP database (2005-2011) was used to identify 4805 pancreaticoduodenectomy patients. Cases were divided at the mean operative time (ORtime) into those ≤373 (n = 2638, 54.9%) vs ≥373 minutes in duration. Complications and outcome measures were compared and predictors of 30-day mortality were assessed. Results: Age ≤ 65 years, male sex, prior chemotherapy, prior radiation, disseminated cancer, diabetes, recent MI, no prior TIA, lower bilirubin and platelet count, and higher prothrombin time were associated with ORtime > 373 minutes. Patients with ORtime > 373 minutes demonstrated more intra-abdominal and superficial infections, wound dehiscence, bleeding requiring transfusion, need for reintubation, septic shock, and returns to OR. ORtime > 373 minutes was associated with longer hospital stay and increased 30-day mortality. ORtime > 373 minutes was a significant and independent predictor in a stepwise model of 30-day mortality. Conclusions: Shorter pancreaticoduodenectomy operative time is associated with fewer complications, shorter hospital stays and lower 30-day mortality after adjusting for patient factors. This may imply that shorter operative time is associated with superior surgical outcome. Operative time may provide insight into surgeon performance and be considered for use as a quality metric.