A Root-Cause Analysis of Mortality Following Major Pancreatectomy

Abstract Introduction Although mortality rates from pancreatectomy have decreased worldwide, death remains an infrequent but profound event at an individual practice level. Root-cause analysis is a retrospective method commonly employed to understand adverse events. We evaluate whether emerging mortality risk assessment tools sufficiently predict and account for actual clinical events that are often identified by root-cause analysis. Methods We assembled a Pancreatic Surgery Mortality Study Group comprised of 36 pancreatic surgeons from 15 institutions in 4 countries. Mortalities after pancreatectomy (30 and 90 days) were accrued from 2000 to 2010. For root-cause analysis, each surgeon "deconstructed" the clinical events preceding a death to determine cause. We next tested whether mortality risk assessment tools (ASA, POSSUM, Charlson, SOAR, and NSQIP) could predict those patients who would die (n=218) and compared their prognostic accuracy against a cohort of resections in which no patient died (n=1,177). Results Two hundred eighteen deaths (184 Whipple's resection, 18 distal pancreatectomies, and 16 total pancreatectomies) were identified from 11,559 pancreatectomies performed by surgeons whose experience averaged 14.5 years. Overall 30-and 90-day mortalities were 0.96% and 1.89%, respectively. Individual surgeon rates ranged from 0% to 4.7%. Only 5 patients died intraoperatively, while the other 213 succumbed at a median of 29 days. Mean patient age was 70 years old (38% were >75 years old). Malignancy was the indication in 90% of cases, mostly pancreatic cancer (57%). Median operative time was 365 min and estimated blood loss was 700 cc (range, 100-16,000 cc). Vascular repair or multivisceral resections were required for 19.7% and 15.1%, respectively. Seventy-seven percent had a variety of major complications before death. Eighty-seven percent required intensive care unit care, 55% were transfused, and 35% were reoperated upon. Fifty percent died during the index admission, while another 11% died after a readmission. Almost half (n=107) expired between 31 and 90 days. Only 11% had autopsies. Operation-related complications contributed to 40% of deaths, with pancreatic fistula being the most evident (14%). Technical errors (21%) and poor patient selection (15%) were cited by surgeons. Of deaths, 5.5% had associated cancer progression-all occurring between 31 and 90 days. Even after root-cause scrutiny, the ultimate cause of death could not be determined for a quarter of the patients-most often between 31 and 90 days. While assorted risk models predicted mortality with variable discrimination from nonmortalities, they consistently underestimated the actual mortality events we report. Conclusion Root-cause analysis suggests that risk prediction should include, if not emphasize, operative factors related to pancreatectomy. While risk models can distinguish between mortalities and nonmortalities in a collective fashion, they vastly miscalculate the actual chance of death on an individual basis. This study reveals the contributions of both comorbidities and aggressive surgical decisions to mortality

Ecological consequences of environmental perturbations associated with offshore hydrocarbon production: a perspective on long-term exposures in the Gulf of Mexico

: A synthesis of the literature on benthic responses to marine pollution suggests that macroinfaunal and meiofaunal communities exhibit repeatable patterns of response to sedimentary contamination generally detectable at high taxonomic levels (even phylum). These responses appear to be jointly driven by intrinsic physiological and ecological characteristics of higher taxa, such that crustaceans (especially amphipods and harpacticoids) and echinoderms are sensitive to toxics whereas polychaetes, oligochaetes, and nematodes (especially non-selective deposit feeders) are enhanced by organic enrichment. Application of this model to the GOOMEX results implies involvement of both toxicity and organic enrichment. Results of toxicity tests and comparisons of observed contaminant concentrations to known effects levels imply that metals drive the toxicity response. We conclude that (1) long-lasting effects of drilling activity exist in the sedimentary environment around gas production platforms, (2) dual effects of toxicity and organic enrichment probably drive readily detectable responses in benthic meiofauna and macroinfauna to 100–200 m, and (3) the failure to detect evidence of exposure or sublethal impacts on fishes and most larger invertebrates is a joint consequence of their mobility over the relevant scales of environmental change and their negligible exposure to hydrocarbons and other contaminants