Mortality factors in pancreatic surgery: A systematic review. How important is the hospital volume?

Mortality after total pancreatectomy in an observational nationwide cohort study

BACKGROUND

As a result of adjuvant therapies for pancreatic cancer including new techniques, such as arterial divestment, and, for instance, as a result of more main-duct intraductal papillary mucinous neoplasms being diagnosed, the number of total pancreatectomies is increasing. Results of these complex operations are only available as centre analyses. The aim of this study was to analyse mortality after total pancreatectomy using real-world data.

METHODS

An observational retrospective study based on routine data of the nationwide German diagnosis-related group (DRG) statistics was performed. All total pancreatectomies from 2010 to 2020 were analysed and classified into four types. Univariable and multivariable analyses were performed for in-hospital mortality as the endpoint.

RESULTS

During the study interval, 13 946 patients underwent total pancreatectomy; 7060 patients (50.6%) underwent type 1 standard total pancreatectomy, 1682 patients (12.1%) underwent type 2 total pancreatectomy (included venous procedures), 3921 patients (28.1%) underwent type 3 total pancreatectomy (included multivisceral resections), and 1283 patients (9.2%) underwent type 4 total pancreatectomy (included arterial procedures). Relaparotomy was necessary for 3232 patients (23.2%). Overall, the in-hospital mortality rate was 22.0% (3072 patients), which varied depending on the type of total pancreatectomy (type 1, 15.6% (1102 patients); type 2, 17.2% (290 patients); type 3, 31.5% (1235 patients); and type 4, 34.7% (445 patients); P < 0.001). The worst outcome of 60.7% in-hospital mortality was related to a small subgroup of 56 patients who were operated on in hospitals that performed one to ten type 4 total pancreatectomies in 2010-2020. With increasing caseload, in-hospital mortality significantly decreased (P < 0.001) for all resection types.

CONCLUSION

The mortality after total pancreatectomy differs significantly between hospitals based on nationwide administrative data across all hospitals. Further in-depth analysis of more granular data to understand the case volume-mortality relationship for total pancreatectomy is warranted.

Not Only Caseload but Also Patient Selection Is Predictive of Mortality After Pancreatic Resection

Background

Centralization of pancreatic surgery in high-volume centers is regarded as a key strategy in improving the outcome quality. However, the specific factors, in addition to higher case volumes, that influence inhospital mortality remain unclear.

Methods

In this retrospective observational study, the German nationwide diagnostic-related groups statistics were analyzed for 86,073 patients with pancreatic resections. Hospitals performing at least 50 resections per year were identified as high-volume pancreatic centers (HVPCs). Statistical analyses compared crude and adjusted estimates of inhospital mortality for patients treated in HVPCs and non-HVPCs. A generalized mixed model was used for risk adjustment, considering various factors such as age group, sex, diagnosis, and comorbidities (ClinicalTrail.gov, NCT06390891).

Results

A total of 24.2% (n = 20,798) of all pancreatic resections were performed in 23 HVPCs. The crude inhospital mortality for all patients undergoing resection was 9.0%. Crude inhospital mortality in HVPCs was 5.5% compared with 10.1% in non-HVPCs (P < 0.001). HVPCs performed more complex resections including more concomitant procedures. On the other hand, HVPCs treated younger patients and patients with less complicated comorbidities. Statistical adjustment of comorbidities and patient characteristics resulted in a significant increase of inhospital mortality from 5.5% to 8.7% in HVPCs.

Conclusions

HVPCs have significantly lower inhospital mortality than the other hospitals. Nevertheless, the superior quality of outcome can be attributed not only to the enhanced expertise of the centers but also, at least in part, to a healthier patient population on average. However, the extent to which this patient selection is due to active selection by the practitioners or other causes remains unclear.

The Value of Textbook Outcome in Benchmarking Pancreatoduodenectomy for Nonfunctioning Pancreatic Neuroendocrine Tumors

BACKGROUND

Textbook outcome (TO) is a composite variable that can define the quality of pancreatic surgery. The aim of this study is to evaluate TO after pancreatoduodenectomy (PD) for nonfunctioning pancreatic neuroendocrine tumors (NF-PanNETs).

PATIENTS AND METHODS

All patients who underwent PD for NF-PanNETs (2007-2016) in different centers were included in this retrospective study. TO was defined as the absence of severe postoperative complications and mortality, length of hospital stay ≤ 19 days, R0 resection, and at least 12 lymph nodes harvested.

RESULTS

Overall, 477 patients were included. The TO rate was 32%. Tumor size [odds ratio (OR) 1.696; p = 0.013], a minimally invasive approach (OR 12.896; p = 0.001), and surgical volume (OR 2.062; p = 0.023) were independent predictors of TO. The annual frequency of PDs increased over time as well as the overall rate of TO. At a median follow-up of 44 months, patients who achieved TO had similar disease-free (p = 0.487) and overall survival (p = 0.433) rates compared with patients who did not achieve TO. TO rate in patients with NF-PanNET > 2 cm was 35% versus 27% in patients with NF-PanNET ≤ 2 cm (p = 0.044). Considering only NF-PanNETs > 2 cm, patients with TO and those without TO had comparable 5-year overall survival rates (p = 0.766) CONCLUSIONS: TO is achieved in one-third of patients after PD for NF-PanNETs and is not associated with a benefit in terms of long-term survival.

Has the trend in pancreatic cancer mortality in Spain started to slow down?

INTRODUCTION

the aim of this study was to describe the trends of pancreatic cancer mortality by autonomous communities (ACs) and gender in Spain (1980-2021).

METHODS

an ecological trend study was performed (with aggregated data obtained from the National Institute of Statistics). Age-standardized mortality rates (ASMRs) for pancreatic cancer (per 100,000) were estimated by direct standardization, using the European standard population. Trends in ASMR (all ages and truncated 35-64 years) were analyzed by sex in each AC using a joinpoint regression model. The annual percent changes (APC) and average annual percentage of change (AAPC) were computed for trends using the joinpoint regression analysis.

RESULTS

in both sexes, ASMRs (all ages) increased significantly (p < 0.05) during the study period (AAPC: 1.5 % in males and 1.8 % in females). The joinpoint analysis identified a turning point in the trends in the late 1980s, which delineates two periods: an initial period of significant increase followed by a period of slowing of the increase (APC: 0.9 % and 1.4 % in males and females respectively; p < 0.05). In both sexes, a significant increase in ASMR (all ages) was observed in all ACs, except in Navarre, where the rates remained stable in males. In males, three ACs (Galicia, Madrid and Navarre) showed a point of inflexion in the time trend around the year 2000 (1999, 2000 and 2001 respectively), when the rates, after a period of significant increase (ACs: 2.6 %, 2.4 %, and 2.4 %, respectively; p < 0.05), stabilized (Galicia and Navarre) or the increase slowed (Madrid). In females, only Madrid showed a point of inflection in 1992, when, after a significant increase, the rates slowed down (1992-2021; APC: 1.5 %; p < 0.05).  Conclusions: the upward trend in pancreatic cancer mortality in some ACs seems to have slowed (in both sexes in Madrid), stabilized (in men in Galicia and Navarre) or turned around (in men aged 30-64 in Navarre).