title: Postoperative complications reduce adjuvant chemotherapy use in resectable pancreatic cancer.
abstract: OBJECTIVE
  To assess the impact of postoperative complications on the receipt of adjuvant chemotherapy.
  
  
  BACKGROUND
  Randomized trials have demonstrated that adjuvant chemotherapy is associated with improved long-term survival. However, pancreatic surgery is associated with significant morbidity and the degree to which complications limit subsequent treatment options is unknown.
  
  
  METHODS
  Patients from the American College of Surgeons National Surgical Quality Improvement Program and the National Cancer Data Base who underwent pancreatic resection for cancer were linked (2006-2009). The associations between complications and adjuvant chemotherapy use or treatment delay (≥ 70 days from surgery) were assessed using multivariable regression methods.
  
  
  RESULTS
  From 149 hospitals, 2047 patients underwent resection for stage I-III pancreatic adenocarcinoma of which 23.2% had at least 1 serious complication. Overall adjuvant chemotherapy receipt was 57.7%: 61.8% among patients not experiencing any complication and 43.6% among those who had a serious complication. Serious complications increased the likelihood of not receiving adjuvant therapy over twofold [odds ratio (OR) = 2.20, 95% confidence interval (CI): 1.73-2.80]. Specific complications associated with adjuvant chemotherapy omission were reintubation (OR = 7.79, 95% CI: 3.59-16.87), prolonged ventilation (OR = 5.92, 95% CI: 3.23-10.86), pneumonia (OR = 2.83, 95% CI: 1.63-4.90), sepsis/shock (OR = 2.76, 95% CI: 2.02-3.76), organ space/deep surgical site infection (OR = 2.19, 95% CI: 1.53-3.13), venous thromboembolism (OR = 1.92, 95% CI: 1.08-3.43), and urinary tract infection (OR = 1.61, 95% CI: 1.02-2.54). Serious complications also doubled the likelihood of delaying adjuvant treatment administration (OR = 2.08, 95% CI: 1.42-3.05). Sensitivity analysis in a younger, healthier patient cohort demonstrated similar associations.
  
  
  CONCLUSIONS
  Postoperative complications are common following pancreatic surgery and are associated with adjuvant chemotherapy omission and treatment delays.
authors.affiliation: *Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL; †Surgical Outcomes and Quality Improvement Center and the Northwestern Institute for Comparative Effectiveness Research (NICER) in Oncology, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL; ‡Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL; §Department of Surgery, University of California, Los Angeles and VA Greater Los Angeles Healthcare System, Los Angeles, CA; ¶Department of Surgical Oncology, MD Anderson Cancer Center, Houston, TX; ‖Department of Surgery, Northshore University Health System, Evanston, IL; and **Department of Surgery, Jesse Brown Veteran Affairs Medical Center, Chicago, IL.
authors.forename: Ryan P
authors.initials: RP
authors.lastname: Merkow
authors.forename: Karl Y
authors.initials: KY
authors.lastname: Bilimoria
authors.forename: James S
authors.initials: JS
authors.lastname: Tomlinson
authors.forename: Jennifer L
authors.initials: JL
authors.lastname: Paruch
authors.forename: Jason B
authors.initials: JB
authors.lastname: Fleming
authors.forename: Mark S
authors.initials: MS
authors.lastname: Talamonti
authors.forename: Clifford Y
authors.initials: CY
authors.lastname: Ko
authors.forename: David J
authors.initials: DJ
authors.lastname: Bentrem
mesh_terms: D000230:Adenocarcinoma / Q000188:drug therapy / Q000473:pathology / Q000601:surgery*; D000368:Aged; D017024:Chemotherapy, Adjuvant / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D010190:Pancreatic Neoplasms / Q000188:drug therapy / Q000473:pathology / Q000601:surgery*; D018579:Patient Selection; D011183:Postoperative Complications / Q000453:epidemiology*; D014481:United States / Q000453:epidemiology