Changes in Pancreatoduodenectomy over Three Decades to Predict Future Pathological and Operative Complexity

Introduction: Patient selection for pancreatoduodenectomy (PD) is largely based upon local experience and established practice. This study sought to firstly observe changes in complexity and patient cohort over time, then predict characteristics of patients undergoing PD in the future. Method: All PDs at our institution between 1988-2020 were reviewed (n=1,878) to observe changing trends in patient and operative factors. Coefficients from regression models were used to quantify the rate of change over time. The resulting models were then plotted to illustrate the trend across the study period, as well as forecasts for subsequent years. Results: Annual volume (7 to 128) and proportion of pancreatic ductal adenocarcinoma (PDAC) (28 to 53%) increased at a linear rate. The proportion of associated vein resection (3 to 25%) and technical difficulty (type 2-4; 5 to 28%) increased in a nonlinear manner. The average age (48 to 67) increased in a log-linear trend. Length of stay reduced by 9.3%, whilst mortality reduced with an odds ratio of 0.69 per decade. By 2030 average age will increase to 69, PDAC will comprise 62% of pathology, 40% will have associated venous resection and 43% will be graded 2-4 in technical difficulty. Length of stay will reduce to 9.6 days and mortality to 2%. Conclusions: Despite increasing complexity of surgery and patient age, length of stay and mortality after PD are reducing. Understanding changes over time permits an estimation of a future surgical cohort where complexity will increase. It is important that surgeons continue to push boundaries.