Clinical impact of developing better practices at the institutional level on surgical outcomes after distal pancreatectomy in 1515 patients: Domestic audit of the Japanese Society of Pancreatic Surgery

Background and Aim: Institutional standardization in the perioperative management of distal pancreatectomy (DP) has not been evaluated in a multicenter setting. The aim of the present study was to assess the influence of institutional standardization on the development of postoperative complications after DP. Methods: Data were collected from 1515 patients who underwent DP in 2006, 2010, and 2014 at 53 institutions in Japan. A standardized institution (SI) was defined as one that implemented >= 6 of 11 quality initiatives according to departmental policy. There were 541 patients in the SI group and 974 in the non-SI group. Clinical parameters were compared between groups. Risk factors for morbidity and mortality were assessed by logistic regression analysis with a mixed-effects model. Results: Proportion of patients who underwent DP in SI increased from 16.5% in 2006 to 46.4% in 2014. The SI group experienced an improved process of care and a lower frequency of severe complications vs the non-SI group (grade III/IV Clavien-Dindo; 22% vs 29%, respectively, clinically relevant postoperative pancreatic fistula; 22% vs 31%, respectively, P < .05 for both). Duration of in-hospital stay in the SI group was significantly shorter than that in the non-SI group (16 [5-183] vs 20 postoperative days [5-204], respectively; P = .002). Multivariate analysis with a mixed-effects model showed that soft pancreas, late drain removal, excess blood loss and long surgical time were risk factors for post-DP complications (P < .05). Pancreatic texture, drain management and surgical factors, but not standardization of care, were associated with a lower incidence of post-DP complications.