Research in context
Evidence before this study
We searched PubMed, Embase, and the Cochrane Library for articles in any language published from database inception to June 20, 2016, before the start of this study, and updated the search on August 1, 2021 with search terms “diagnosis”, “management”, “pancreatic resection”, and “complications”, and synonyms. We found no studies that evaluated a multimodal intervention for recognition and management of complications after pancreatic resection. We found many observational studies that evaluated different diagnostic modalities for postoperative pancreatic fistula. We published a systematic review on this topic in 2020. Our 2020 review included all diagnostic tests that showed an association with postoperative pancreatic fistula in at least two cohorts. Identified variables were body temperature, C-reactive protein, white blood cell count, serum amylase amount, drain amylase amount, non-serous drain efflux, and peripancreatic fluid collections on CT scan. To our knowledge, no randomised trials have been published on complication management after pancreatic resection. However, several observational studies suggested the superiority of a minimally invasive treatment strategy compared with reoperation.
Added value of this study
To our knowledge, our study provides the first high-quality evidence that early recognition and minimally invasive management of complications after pancreatic resection, before they become clinically relevant, can interrupt the cascade of events that lead to organ failure and death. This effect was measured both in high-volume centres and in low–medium volume hospitals.
Implications of all the available evidence
The multidisciplinary, multimodal algorithm for daily bedside use was designed using data from our mandatory nationwide audit, guideline inventories, Dutch national meetings and international consensus meetings, and a comprehensive systematic review of the literature. The algorithm was therefore based on the best available evidence. After combining this evidence with our study findings, we believe that after pancreatic resection, all patients should receive a structured daily evaluation to aid the early recognition and management of complications before these become clinically relevant. This provision will considerably improve clinical outcomes and decrease the failure to rescue rate, which is an international priority in surgical practice and among policy makers. Our simple to use and low-cost algorithm, and the method for its implementation, can be modified easily for use in other types of surgery. Future studies could evaluate further improvements to the algorithm and the adaptation of the algorithm in other clinical contexts.