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Failure To Rescue After Pancreatoduodenectomy: A Transatlantic Analysis
*Elizabeth M. Gleeson1, Henry A. Pitt2, *Tara M. Mackay3, *Ulrich F. Wellner4, *Caroline Williamsson5, *Oliver R. Busch3, *Bas Groot Koerkamp6, *Tobias Keck4, *Hjalmar C. van Santvoort7, *Bobby Tingstedt5, *Marc G. Besselink3
1Icaham School of Medicine at Mount Sinai, New York, NY;2Rutgers Cancer Institute of New Jersey, New Brunswick, NJ;3Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands4University of Lubeck, Lubeck, Germany5Lund University, Lund, Sweden6Erasmus Medical Center Cancer Institute, Rotterdam, Netherlands7University Medical Center Utrecht, Utrecht, Netherlands

Background: Failure to rescue (FTR), or mortality after a major complication, is a quality metric created to compare hospital results. FTR has been studied in North American patients undergoing pancreatoduodenectomy, but data from Europe are scarce. This analysis aims to compare FTR after pancreatoduodenectomy across the Atlantic.
Methods: Patients who underwent pancreatoduodenectomy from 2014-17 in North America, the Netherlands, Sweden and Germany were identified from their respective registries. Patients who developed a major complication (Clavien-Dindo ≥ 3) or a clinically relevant postoperative pancreatic fistula (CR-POPF) were included. Preoperative, intraoperative and postoperative variables were compared between patients with and without FTR. Variables significant in univariable analysis were entered into a logistic regression to identify independent predictors of FTR.
Results: Major complications occurred in 6,188 of 22,983 pancreatoduodenectomy patients (26.9%), and 504 patients (8.2%) had FTR. FTR rates in North America and Europe were significantly different (5.4% vs 12%, p<0.001). Factors contributing to differences in patients who developed FTR are shown in the Table. On multivariable analysis, factors independently associated with FTR were age, ASA ≥ 3, European continent, development of a CR-POPF, organ failure, life threatening complication, radiologic intervention or reoperation.
Conclusions: FTR is more common in Europe than in North America. Older patients with severe systemic disease are more difficult to rescue. Complications manageable by interventional radiologists have better outcomes than those requiring reoperation.

Table. Multivariable analysis for Failure-to-Rescue (FTR) among patients with a major complication.
Adjusted ORLower LimitUpper Limitp-value
Age1.0301.0131.047<0.001
ASA ≥ 31.6451.0242.640.039
Europe3.5992.146.051<0.001
POPF B/C0.5830.3960.8580.006
Organ Failure2.9281.5335.5920.001
Life Threatening Complication8.3354.00317.355<0.001
Radiologic Intervention0.4590.3140.671<0.001
Reoperation1.5781.1422.1810.006


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