The PAncreatic Surgery Composite Endpoint PACE - Development and Validation of a Clinically Relevant Endpoint Requiring Lower Sample Sizes

Felix Nickel; Christoph Kuemmerli; Philip C Müller; Mona W Schmidt; Leon P Schmidt; Philipp Wise; Rosa Klotz; Christine Tjaden; Markus Diener; Pascal Probst; Thilo Hackert; Markus W Büchler

doi:10.1097/SLA.0000000000006194

The PAncreatic Surgery Composite Endpoint PACE - Development and Validation of a Clinically Relevant Endpoint Requiring Lower Sample Sizes

Ann Surg. 2024 Jan 12. doi: 10.1097/SLA.0000000000006194. Online ahead of print.

Authors

Felix Nickel^{1

2}, Christoph Kuemmerli³, Philip C Müller³, Mona W Schmidt⁴, Leon P Schmidt⁴, Philipp Wise^{1

2}, Rosa Klotz¹, Christine Tjaden¹, Markus Diener⁵, Pascal Probst⁶, Thilo Hackert^{1

2}, Markus W Büchler^{1

7}

Affiliations

¹ Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany.
² Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
³ Department of Surgery, Clarunis - University Centre for Gastrointestinal and Liver Diseases, Basel, Switzerland.
⁴ Department of Gynecology and Obstetrics, University Medical Centre Mainz, Mainz, Germany.
⁵ Department of General, Visceral, and Thoracic Surgery, Hospital of Nuremberg, Nuremberg, Germany.
⁶ Department of Surgery, Cantonal Hospital Thurgau, Frauenfeld, Switzerland.
⁷ Botton-Champalimaud Pancreatic Cancer Center, Champalimaud Foundation, Lisbon, Portugal.

PMID: 38214195
DOI: 10.1097/SLA.0000000000006194

Abstract

Objective: To provide a composite endpoint in pancreatic surgery.

Summary background data: Single endpoints in prospective and randomized studies have become impractical due to their low frequency and the marginal benefit of new interventions.

Methods: Data from prospective studies were used to develop (n=1273) and validate (n=544) a composite endpoint based on postoperative pancreatic fistula, post-pancreatectomy hemorrhage as well as reoperation and reinterventions. All patients had pancreatectomies of different extents. The association of the developed PAncreatic surgery Composite Endpoint (PACE) with prolonged length of hospital stay (LOS) >75th percentile and mortality was assessed. A single-institution database was used for external validation (n = 2666). Sample size calculations were made for single outcomes and the composite endpoint.

Results: In the internal validation cohort, the PACE demonstrated an AUC of 78.0%, a sensitivity of 90.4% and a specificity of 67.6% in predicting a prolonged LOS. In the external cohort, the AUC was 76.9%, the sensitivity 73.8% and the specificity 80.1%. The 90-day mortality rate was significantly different for patients with a positive versus a negative PACE both in the development and internal validation cohort (5.1% vs 0.9%; P< 0.001), as well as in the external validation cohort (8.5% vs 1.2%, P< 0.001). The PACE enabled sample size reductions of up to 80.5% compared to single outcomes.

Conclusion: The PACE performed well in predicting prolonged hospital stays and can be used as a standardized and clinically relevant endpoint for future prospective trials enabling lower sample sizes and therefore improved feasibility compared to single outcome parameters.