Document Type
Article
Publication Date
10-8-2025
Abstract
Background: Failure to rescue (FTR), defined as death after major postoperative complications, is a critical quality indicator in pancreatic cancer surgery. Despite advances in surgical techniques and perioperative care, FTR rates remain high and vary across institutions. Methods: This systematic review uses a narrative synthesis followed by PRISMA 2020. A PubMed search (1992-2025) identified 83 studies; after screening, 52 studies (2010-2025) were included. Eligible designs were registry-based, multicenter, single-center, or prospective audits. Given substantial heterogeneity in study designs, FTR definitions, and outcome measures, a narrative synthesis was performed; no formal risk-of-bias assessment or meta-analysis was conducted. Results: Definitions of FTR varied (in-hospital, 30-day, 90-day, severity-based, and complication-specific cases). Reported rates differed by definition: average reported rates were 13.2% for 90-day CD ≥ III (G1); 10.3% for in-hospital/30-day CD ≥ III (G3); and 7.4% for 30-day "serious/major" morbidity (G8). Absolute differences were +3.0 and +2.9 percentage points (exploratory, descriptive comparisons). Five domains were consistently associated with lower FTR: (i) centralization to high-volume centers; (ii) safe adoption/refinement of surgical techniques; (iii) optimized perioperative management including early imaging and structured escalation pathways; (iv) patient-level risk stratification and prehabilitation; and (v) non-technical skills (NTSs) such as decision-making, situational awareness, communication, teamwork, and leadership. Among NTS domains, stress and fatigue management were not addressed in any included study. Limitations: Evidence is predominantly observational with substantial heterogeneity in study designs and FTR definitions; the search was limited to PubMed; and no formal risk-of-bias, publication-bias assessment, or meta-analysis was performed. Consequently, estimates and associations are descriptive/associative with limited certainty and generalizability. Conclusions: NTSs were rarely used or measured across the included studies, with validated instruments; quantitative assessment was uncommon, and no study evaluated stress or fatigue management. Reducing the FTR after pancreatic surgery will require standardized, pancreas-specific definitions of FTR, process-level rescue metrics, and deliberate strengthening of NTS. We recommend a pancreas-specific operational definition with an explicit numerator/denominator: numerator = all-cause mortality within 90 days of surgery; denominator = patients who experience major complications (Clavien-Dindo grade III-V, often labeled "CD ≥ 3"). Addressing the gaps in stress and fatigue management and embedding behavioral metrics into quality improvement programs are critical next steps to reduce preventable mortality after complex pancreatic cancer procedures.
Recommended Citation
Uramatsu, Masashi; Fujisawa, Yoshikazu; Barach, Paul; Osakabe, Hiroaki; Matsumoto, Moe; and Nagakawa, Yuichi, "Failure to Rescue After Surgery for Pancreatic Cancer: A Systematic Review and Narrative Synthesis of Risk Factors and Safety Strategies" (2025). College of Population Health Faculty Papers. Paper 230.
https://jdc.jefferson.edu/healthpolicyfaculty/230
Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 License.
Language
English
Included in
Diagnosis Commons, Digestive System Diseases Commons, Patient Safety Commons, Surgery Commons
Comments
This article is the author’s final published version in Cancers, Volume 17, Issue 19, 2025, Article number 3259.
The published version is available at https://doi.org/10.3390/cancers17193259. Copyright © 2025 by the authors.