Pancreatoduodenectomy at the Verona Pancreas Institute: The Evolution of Indications, Surgical Techniques and Outcomesanalysis of 3000 Consecutive Cases

Purpose: The indications, surgical techniques, and perioperative management of pancreatoduodenectomy (PD) have profoundly evolved during the last 20 years. Aim of the present study was to critical reappraise the experience at our high-volume Institution to obtain new insights for future directions. Methods: All consecutive PDs performed during the last 20 years at the Verona Pancreas Institute were divided into four 5-year timeframes and retrospectively analyzed in terms of indications, intraoperative features and surgical outcomes. Significant milestones were provided to understand practice changes using a before-after analysis method. Results: The study population consisted of 3000 patients. The median age, ASA ³ 3 and non-benchmark cases significantly increased over time (p < 0.005). Pancreatic cancer was the leading indication, representing the 60% of cases/year in the last timeframe, 40% of which after receiving neoadjuvant treatments. Conversely, after the development of International Guidelines, the proportion of resected cystic neoplasms has progressively while thoroughly decreased. In the setting of augmented complexity of surgery for pancreatic cancer, the evolution of technology, surgical technique and postoperative management allowed to maintain favorable surgical outcomes over time, with a stable 20.0% Clavien-Dindo grade ³ 3, 11.7% failure to rescue and 2.3% in-hospital mortality rates. Postoperative pancreatic fistula, hemorrhage and delayed gastric emptying incidence were 22.4%, 13.4% and 12.4%, respectively. Conclusion: Pancreatoduodenectomy significantly evolved in Verona during the past two decades. Surgeries of greater complexity are currently performed on increasingly frailer patients, mostly for pancreatic cancer and often after neoadjuvant chemotherapy. However, the progression of all fields of pancreatic surgery, including the expanding use of POPF mitigation strategies, has allowed to maintain satisfactory outcomes.