Effect of hospital volume on in-hospital mortality with pancreaticoduodenectomy

Extending Quality Improvement for Pancreatoduodenectomy Within the High-Volume Setting: The Experience Factor

OBJECTIVE

To analyze the association of a surgeon's experience with postoperative outcomes of pancreatoduodenectomies (PDs) when stratified by Fistula Risk Score (FRS).

BACKGROUND

Centralization is now well-established for pancreatic surgery. Nevertheless, the benefits of individual surgeon's experience in high-volume settings remain undefined.

METHODS

Pancreatoduodenectomies performed by 82 surgeons across 18 international specialty institutions (median: 140 PD/year) were analyzed. Surgeon cumulative PD volume was linked with postoperative outcomes through multivariable models, adjusted for patient/operative characteristics and the FRS. Then, surgeon experience was also stratified by the 10, previously defined, most clinically impactful scenarios for clinically relevant pancreatic fistula (CR-POPF) development.

RESULTS

Of 8189 PDs, 18.7% suffered severe complications (Accordion≥3), 4.8% were reoperated upon and 2.2% expired. Although the most experienced surgeons (top-quartile; >525 career PDs) more often operated on riskier cases, their experience was significantly associated with declines in CR-POPF ( P <0.001), severe complications ( P =0.008), reoperations ( P <0.001), and length of stay (LOS) ( P <0.001)-accentuated even more in the most impactful FRS scenarios (2830 patients). Risk-adjusted models indicate male sex, increasing age, ASA class, and FRS, but not surgeon experience, as being associated with severe complications, failure-to-rescue, and mortality. Instead, upper-echelon experience demonstrates significant reductions in CR-POPF (OR 0.66), reoperations (OR 0.64), and LOS (OR 0.65) in moderate-to-high fistula risk circumstances (FRS≥3, 68% of cases).

CONCLUSIONS

At specialty institutions, major morbidity, mortality, and failure-to-rescue are primarily associated with baseline patient characteristics, while cumulative surgical experience impacts pancreatic fistula occurrence and its attendant effects for most higher-risk pancreatoduodenectomies. These data also suggest an extended proficiency curve exists for this operation.

The Learning Curve for Pancreaticoduodenectomy: The Experience of a Single Surgeon

BACKGROUND AND AIMS

Pancreaticoduodenectomy (PD) is a complex and high-skill demanding procedure often associated with significant morbidity and mortality. However, the results have improved over the past two decades. However, there is a paucity of research concerning the learning curve for PD. Our aim was to report the outcomes of 100 consecutive PDs representing a single surgeon's learning curve and to depict the factors that influenced the learning process.

METHODS

We reviewed the first 121 PDs performed at our academic center (2013-2019) by a single surgeon; 110 were PDs (5 laparoscopic and 105 open) and 11 were total PDs (1 laparoscopic and 10 open). Subsequent statistics was performed on the first 100 PDs, with attention paid to the learning curve and survival rate at 5 years. The data were analyzed comparing the first 50 cases (Group 1) to the last 50 cases (Group 2).

RESULTS

The most frequent histopathological tumor type was pancreatic ductal adenocarcinoma (50%). A total of 39% of patients had preoperative biliary drainage and 45% presented with positive biliary cultures. The preferred reconstruction technique included pancreaticogastrostomy (99%), in situ hepaticojejunostomy (70%), and precolic gastro-jejunal anastomosis (88%). Postoperative complications included biliary fistula (1%), pancreatic fistula (8%), pancreatic stump bleeding (4%), and delayed gastric emptying (13%). The mean operative time decreased after the first 50 cases (p < 0.001) and blood loss after 60 cases (p = 0.046). R1 resections lowered after 25 cases (p = 0.025). Vascular resections (17%) did not influence the rate of complications (p = 0.8). The survival rate at 5 years for pancreatic adenocarcinoma was 32.93%.

CONCLUSIONS

Outcomes improve as surgeon experience increases, with proper training being the most important factor for minimizing the impact of the learning curve over the postoperative complications. Analyzing the learning curve from the perspective of a single surgeon is mandatory for accurate statistical results and interpretation.

Understanding Variation in In-hospital Mortality After Major Surgery in the United States

OBJECTIVES

We aimed to quantify the contributions of patient characteristics (PC), hospital structural characteristics (HC), and hospital operative volumes (HOV) to in-hospital mortality (IHM) after major surgery in the United States (US).

BACKGROUND

The volume-outcome relationship correlates higher HOV with decreased IHM. However, IHM after major surgery is multifactorial, and the relative contribution of PC, HC, and HOV to IHM after major surgery is unknown.

STUDY DESIGN

Patients undergoing major pancreatic, esophageal, lung, bladder, and rectal operations between 2006 and 2011 were identified from the Nationwide Inpatient Sample linked to the American Hospital Association survey. Multilevel logistic regression models were constructed using PC, HC, and HOV to calculate attributable variability in IHM for each.

RESULTS

Eighty thousand nine hundred sixty-nine patients across 1025 hospitals were included. Postoperative IHM ranged from 0.9% for rectal to 3.9% for esophageal surgery. Patient characteristics contributed most of the variability in IHM for esophageal (63%), pancreatic (62.9%), rectal (41.2%), and lung (44.4%) operations. HOV explained < 25% of variability for pancreatic, esophageal, lung, and rectal surgery. HC accounted for 16.9% and 17.4% of the variability in IHM for esophageal and rectal surgery. Unexplained variability in IHM was high in the lung (44.3%), bladder (39.3%), and rectal (33.7%) surgery subgroups.

CONCLUSIONS

Despite recent policy focus on the volume-outcome relationship, HOV was not the most important contributor to IHM for the major organ surgeries studied. PC remains the largest identifiable contributor to hospital mortality. Quality improvement initiatives should emphasize patient optimization and structural improvements, in addition to investigating the yet unexplained sources contributing to IHM.

A Comparison of Clinical and Cost Outcomes After Pancreatectomies at a Safety-net Hospital using a National Registry

BACKGROUND

Our institution (UFHJ) meets the criteria of both a large, specialized medical center (LSCMC) and a safety-net hospital (AEH). Our aim is to compare pancreatectomy outcomes at UFHJ against other LSCMCs, AEHs, and against institutions that meet criteria for both LSCMC and AEH. In addition, we sought to evaluate differences between LSCMCs and AEHs.

MATERIALS AND METHODS

Pancreatectomies for pancreatic cancer were queried from the Vizient Clinical Data Base (2018 to 2020). Clinical and cost outcomes were compared between UFHJ and LSCMCs, AEHs, and a combined group, respectively. Indices >1 indicated the observed value was greater than the expected national benchmark value.

RESULTS

The mean number of pancreatectomy cases performed per institution in the LSCMC group was 12.15, 11.73, and 14.31 in 2018, 2019, and 2020, respectively. At AEHs, 25.33, 24.56, and 26.37 mean cases per institution per year, respectively. In the combined group of both LSCMCs and AEHs, 8.10, 7.60, and 7.22 mean cases, respectively. At UFHJ, 17, 34, and 39 cases were performed each year, respectively. Length of stay index decreased below national benchmarks at UFHJ (1.08 to 0.82), LSCMCs (0.91 to 0.85), and AEHs (0.94 to 0.93), with an increasing case mix index at UFHJ (3.33 to 4.20) from 2018 to 2020. In contrast, length of stay index increased in the combined group (1.14 to 1.18) and overall was the lowest at LSCMCs (0.89). Mortality index declined at UFHJ (5.07 to 0.00) below national benchmarks compared with LSCMCs (1.23 to 1.29), AEHs (1.19 to 1.45), and the combined group (1.92 to 1.99), and was significantly different between all groups ( P <0.001). Thirty-day re-admissions were lower at UFHJ (6.25% to 10.26%) compared with LSCMCs (17.62% to 16.83%) and AEHs (18.93% to 15.51%), and significantly lower at AEHs compared with LSCMCs ( P <0.001). Notably, 30-day re-admissions were lower at AEHs compared with LSCMCs ( P <0.001) and declined over time and were the lowest in the combined group in 2020 (17.72% to 9.52%). Direct cost index at UFHJ declined (1.00 to 0.67) below the benchmark compared with LSCMCs (0.90 to 0.93), AEHs (1.02 to 1.04), and the combined group (1.02 to 1.10). When comparing LSCMCs and AEHs, there were no significant differences between direct cost percentages ( P =0.56); however, the direct cost index was significantly lower at LSCMCs.

CONCLUSION

Pancreatectomy outcomes at our institution have improved over time exceeding national benchmarks and often were significant to LSCMCs, AEHs, and a combined comparator group. In addition, AEHs were able to maintain good quality care when compared with LSCMCs. This study highlights the role that safety-net hospitals can provide high-quality care to a medically vulnerable patient population in the presence of high-case volume.

A contemporary analysis of the volume-outcome relationship for extracorporeal membrane oxygenation in the United States

BACKGROUND

A paradoxical increase in mortality following extracorporeal membrane oxygenation at high-volume centers has previously been demonstrated. We examined the association between annual hospital volume and outcomes within a contemporary, national cohort of extracorporeal membrane oxygenation patients.

METHODS

All adults requiring extracorporeal membrane oxygenation for postcardiotomy syndrome, cardiogenic shock, respiratory failure, or mixed cardiopulmonary failure were identified in the 2016 to 2019 Nationwide Readmissions Database. Patients undergoing heart and/or lung transplantation were excluded. A multivariable logistic regression with hospital extracorporeal membrane oxygenation volume parametrized as restricted cubic splines was developed to characterize the risk-adjusted association between volume and mortality. The volume corresponding to the maximum of the spline (43 cases/year) was used to categorize centers as low- or high-volume.

RESULTS

An estimated 26,377 patients met the study criteria, and 48.7% were managed at high-volume hospitals. Patients at low- and high-volume hospitals had similar age, sex, and rates of elective admission. Notably, patients at high-volume hospitals less frequently required extracorporeal membrane oxygenation for postcardiotomy syndrome but more commonly for respiratory failure. After risk adjustment, high-volume hospital status was associated with reduced odds of in-hospital mortality, relative to low-volume hospitals (adjusted odds ratio 0.81, 95% confidence interval 0.78-0.97). Interestingly, patients at high-volume hospitals faced a 5.2-day increment in length of stay (95% confidence interval 3.8-6.5) and $23,500 in attributable costs (95% confidence interval 8,300-38,700).

CONCLUSION

The present study found that greater extracorporeal membrane oxygenation volume was associated with decreased mortality but higher resource use. Our findings may help inform policies regarding access to and centralization of extracorporeal membrane oxygenation care in the United States.

Long-term clinical outcomes of a fully covered self-expandable metal stent for refractory pancreatic strictures in symptomatic chronic pancreatitis: An 11-year follow-up study

BACKGROUND AND AIMS

A fully covered self-expandable metal stent (FCSEMS) has recently been applied in the management of chronic pancreatitis patients with pancreatic strictures. However, related long-term effects remain unclear. This study aimed to evaluate the long-term outcomes of FCSEMS placement in chronic pancreatitis patients with refractory strictures.

METHOD

We retrospectively reviewed our database for patients undergoing FCSEMS placement for refractory pancreatic strictures between September 2008 and December 2010. The main outcomes were technical, radiological, and clinical success, as well as recurrence and adverse events.

RESULTS

A total of 35 patients were included. Technical success was achieved in all patients. The median FCSEMS indwelling time was 3.2 months (interquartile range [IQR], 3.0-4.9 months). Radiological success was achieved in all patients (complete, n = 2; partial, n = 33). Clinical success was achieved in 29 patients (82.9%; complete analgesic cessation, n = 19; analgesic reduction >50%, n = 11). During the median follow-up of 136 months, (IQR, 85.8-145.5 months), eight patients (22.9%) experienced recurrence. The median interval from stent removal to recurrence was 24.9 months (IQR, 11.3-30.3 months). Biliary obstruction, an early adverse event, occurred in two patients (5.7%); the late adverse event stent-induced de novo stricture was observed in 17 patients (48.6%).

CONCLUSIONS

Our findings suggest that an FCSEMS is effective for relieving refractory strictures in chronic pancreatitis. However, FCSEMSs were associated with stent-induced de novo strictures in nearly half of the patients. Prospective studies are required to further evaluate the long-term efficacy and safety of FCSEMSs in chronic pancreatitis.

Neoadjuvant therapy at local versus outside institutions does not adversely impact surgical timing or long-term outcomes in patients with pancreatic adenocarcinoma

BACKGROUND

Although high-volume centers are known to have better surgical outcomes, patients with pancreatic adenocarcinoma often receive chemotherapy at treatment centers closer to home. This study aimed to determine whether treatment site of neoadjuvant therapy relative to surgery location impacts surgical timing and long-term outcomes.

METHODS

All patients with pancreatic adenocarcinoma who underwent oncologic resection at a single, high-volume institution between January 2016 and February 2020 and had neoadjuvant chemotherapy before surgery were queried from a prospectively maintained database. Patients were sorted based on location of neoadjuvant chemotherapy.

RESULTS

A total of 179 patients were included in the study. Seventy-four (41.3%) patients received neoadjuvant chemotherapy at the same institution as their surgery (group A), 20 (11.2%) received chemotherapy outside of their surgical institution but within the same hospital/healthcare system (group B), and 85 (47.5%) received chemotherapy at an outside location (group C). The time from completion of neoadjuvant therapy to surgery was not significantly different between groups (A vs B vs C median [interquartile range]: 34.5 [14] vs 41.5 [24] vs 36 [22] days, P = .08). Thirty-day readmission rate was lower in group A (n (%): 1 (1.4%) vs 2 (10.0%) vs 11 (12.9%), P = .02). However, the 90-day mortality and overall survival did not differ significantly between groups.

CONCLUSION

Patients may receive neoadjuvant therapy at local centers without impacting surgical scheduling. Although these patients may experience higher postoperative readmission rates, perioperative mortality and long-term survival are not adversely affected by location of chemotherapy. Multidisciplinary care can be effectively practiced in different locations without affecting overall outcomes in patients with pancreatic adenocarcinoma.

Selective use of pancreatic duct occlusion during pancreaticoduodenectomy in patients with a small-size duct and atrophic parenchyma in the distal pancreas: A retrospective study

Background

Despite the advancements in surgical techniques, postoperative pancreatic fistula (POPF) remains a potentially life-threatening complication of pancreaticoduodenectomy (PD). Pancreatic duct occlusion (PDO) without anastomosis has also been proposed to alleviate the clinical consequences of POPF in selected patients after PD.

Objectives

To assess the safety and effectiveness of PDO with mechanical closure after PD in patients with an atrophic pancreatic body-tail and a small pancreatic duct.

Methods

We retrospectively identified two female and two male patients from April 2019 to October 2020 through preoperative computed tomography of the abdomen. Among them, three patients underwent PDO with mechanical closure after PD, and one underwent PDO after pylorus-preserving PD. In addition, patients' medical records and medium-and long-term follow-up data were analyzed.

Results

Postoperative histological examination revealed a solid pseudopapillary tumor in two patients, pancreatic ductal adenocarcinoma in one patient, and chronic pancreatitis with pancreatic duct stones in one patient. However, none of the patients developed biochemical or clinically relevant POPF, with no postpancreatectomy hemorrhage, biliary leakage, delayed gastric emptying, intra-abdominal abscess, or chyle leakage. Among the four patients, three developed new-onset diabetes mellitus, and one had impaired glucose tolerance. Furthermore, three patients received pancreatic enzyme supplementation at a dose of 90,000 Ph. Eur. units/d, and one was prescribed a higher dose of 120,000 Ph. Eur. units/d.

Conclusions

PDO with mechanical closure is an alternative approach for patients with an atrophic pancreatic body-tail and a small pancreatic duct after PD. Therefore, further evidence should evaluate the potential benefits of selective PDO in these patients.

Fragmentation of Care in Pancreatic Cancer: Effects on Receipt of Care and Survival

BACKGROUND

The impact of fragmentation of care (FC), i.e., receipt of care at > 1 institution, on treatment of pancreatic cancer is unknown. The purpose of this study was to determine factors associated with FC in curative-intent treatment of pancreatic cancer (PDAC) patients and evaluate how FC affects survival outcomes.

METHODS

Using the National Cancer Database (NCDB), data on stage I-III PDAC patients diagnosed 2006-2016 were extracted. Multiple logistic regression analyses were performed to identify factors predictive of FC and survival.

RESULTS

Of the 20,013 patients identified, 24.1% had FC. Factors predictive of FC were stage-III tumors (odds ratio [OR] 1.36; p = 0.014), higher median-income [third quartile (OR 1.38; p = 0.006) and highest-quartile (OR 1.50; p = 0.003)], care at high-volume facility (OR 1.47; p < 0.001), and receipt of multi-modal therapy (OR 1.69; p < 0.001). In contrast, age > 80 years (OR 0.82; p = 0.018), Black (OR 0.85; p = 0.013) or Asian race (OR 0.76; p = 0.033), Charlson comorbidity-index 2 (OR 0.85; p = 0.033), treatment at non-academic facility (OR 0.87; p = 0.041), and non-private insurance were negatively predictive of FC. FC independently predicted decreased 30-day [OR 0.57; p < 0.001] and 90-day mortality [OR 0.61; p < 0.001] and improved overall survival [hazard ratio 0.91; p < 0.001].

DISCUSSION

Sociodemographic factors are significantly associated with FC in curative-intent treatment of PDAC patients. FC was found to predict improved 30-day, 90-day, and overall survival outcomes.

Assessment of exo- and endocrine function of pancreas following distal pancreatectomy

Aim. The assessment of pancreatic resection volume influence on exo- and endocrine pancreatic functions. Materials and methods. The resected pancreatic volume influence was assessed in 47 patients: 31 (66%) patients after resections of pancreatic body and tail, and 16 (34%) patients after distal resections. The exocrine pancreatic function was assessed by pancreatic fecal elastase 1 as well as endocrine pancreatic function was assessed by C-peptide level measurement. Computed tomography with intravenous contrast enhancement and postprocessing was used for pre- and postoperative pancreatic volume assessment. All tests were performed before and 1, 3, and 6 months after surgery. Results. Type of surgery had no influence on C-peptide and pancreatic fecal elastase 1 levels (p0.05). Exo- and endocrine pancreatic functions markers tended to decrease in 1st month after surgery with consequent functions restoration towards 6 months after surgery. There were 15 (35.7%) patients from 42 patients with normal exocrine pancreatic function with a fecal elastase 1 level decrease to 114.761.8 g/g; exocrine insuficiency remained only in 2 (4.8%) patients after 6 months after surgery. C-peptide concentration decrease before surgery to less than 1.1 ng/ml was noticed only in 8 (17%) patients. C-peptide concentration decreased in 30 (63.8%) patients in 1st month after surgery, but after 6 months after surgery, C-peptide level decrease was only in 7 (14.9%) patients. Conclusion. The exo- and endocrine function of the pancreas is restored in more than 80% of patients after DR. Probably it could be associated with the activation of the pancreatic compensatory abilities.

Quality assurance and quality control in surgical oncology

Even though surgery has remained a key component within multi-disciplinary cancer care, the expectations have changed. Instead of serving as a modality to free a patient of a mass at all means and at the risk of high morbidity, modern cancer surgery is expected to provide adequate tumor clearance with lowest invasiveness. This review summarizes the evidence on quality assurance in surgical oncology and gives a comprehensive overview of quality improvement tools.

Hospital Surgical Volume Is Poorly Correlated With Delivery of Multimodal Treatment for Localized Pancreatic Cancer

Using Donabedian’s quality of care model, this study assessed process (hospital multimodal treatment) and structure (hospital surgical case volume) measures to evaluate localized pancreatic cancer outcomes.

Whipple’s operation with a modified centralization concept: A model in low-volume Caribbean centers

Conventional data suggest that complex operations, such as a pancreaticoduodenectomy (PD), should be limited to high volume centers. However, this is not practical in small, resource-poor countries in the Caribbean. In these settings, patients have no option but to have their PDs performed locally at low volumes, occasionally by general surgeons. In this paper, we review the evolution of the concept of the high-volume center and discuss the feasibility of applying this concept to low and middle-income nations. Specifically, we discuss a modification of this concept that may be considered when incorporating PD into low-volume and resource-poor countries, such as those in the Caribbean. This paper has two parts. First, we performed a literature review evaluating studies published on outcomes after PD in high volume centers. The data in the Caribbean is then examined and we discuss the incorporation of this operation into resource-poor hospitals with modifications of the centralization concept. In the authors’ opinions, most patients who require PD in the Caribbean do not have realistic opportunities to have surgery in high-volume centers in developed countries. In these settings, their only options are to have their operations in the resource-poor, low-volume settings in the Caribbean. However, post-operative outcomes may be improved, despite low-volumes, if a modified centralization concept is encouraged.

"Peas in a Pod": Clustering minorly injured trauma patients together during their hospitalization results in decreased hospital costs and fewer inpatient complications

BACKGROUND

Trauma patient care is complex. Clustering these patients within the hospital seems intuitive. This study's purpose was to explore the benefits of trauma patient clustering, hypothesizing these patients will have decreased costs and better outcomes.

METHODS

This was an analysis of all adult (18-99 years) trauma patients admitted from 1/2017-1/2019 without an intensive care unit stay. Patients were grouped into those admitted to the trauma unit (TU) versus non-trauma units (NTU). Outcomes evaluated between groups were baseline demographics, direct costs, complication rates (using our TQIP registry), and discharge location. T-test, median test, and chi squared test were used. Linear regression was performed. Significance was set at p < 0.05.

RESULTS

1481 patients (684 TU and 797 NTU) were analyzed. TU patients were younger. Injury Severity Score, mortality, and hospital length of stay were similar between groups. Direct hospital costs were decreased for TU patients ($4941(±$4740) versus $5639(±$4897), p = 0.006). Fewer TU patients experienced inpatient complications (7.8% versus 13.5%, p < 0.001). More TU patients were discharged to home (78.9% versus 73.8%, p = 0.02). Linear regression analysis demonstrated admission to NTUs predicted a direct cost increase of $766.35 (p < 0.001).

CONCLUSIONS

Clustering minorly injured trauma patients on a dedicated unit resulted in reduced costs, decreased complications, and higher likelihood for discharge to home.

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

BACKGROUND

How the extent of confounding adjustment impact (hospital) volume-outcome relationships in published studies on pancreatic cancer surgery is unknown.

METHODS

A systematic literature search was conducted for studies that investigated the relationship between volume and outcome using a risk adjustment procedure by querying the following databases: PubMed, Cochrane Central Register of Controlled Trials, Livivo, Medline and the International Clinical Trials Registry Platform (last query: 2020/09/16). Importance of risk-adjusting covariates were assessed by effect size (odds ratio, OR) and statistical significance. The impact of covariate adjustment on hospital (or surgeon) volume effects was analyzed by regression and meta-regression models.

RESULTS

We identified 87 studies (75 based on administrative data) with nearly 1 million patients undergoing pancreatic surgery that included in total 71 covariates for risk adjustment. Of these, 33 (47%) had statistically significant effects on short-term mortality and 23 (32%) did not, while for 15 (21%) factors neither effect size nor statistical significance were reported. The most important covariates for short term mortality were patient-specific factors. Concerning the covariates, single comorbidities (OR: 4.6, 95% CI: 3.3 to 6.3) had the strongest impact on mortality followed by hospital volume (OR: 2.9, 95% CI: 2.5 to 3.3) and the procedure (OR: 2.2, 95% CI: 1.9 to 2.5). Among the single comorbidities, coagulopathy (OR: 4.5, 95% CI: 2.8 to 7.2) and dementia (OR: 4.2, 95% CI: 2.2 to 8.0) had the strongest influence on mortality. The regression analysis showed a significant decrease hospital volume effect with an increasing number of covariates considered (OR: 0.06, 95% CI: 0.10 to -0.03, P < 0.001), while such a relationship was not observed for surgeon volume (P = 0.35).

CONCLUSIONS

This analysis demonstrated a significant inverse relationship between the extent of risk adjustment and the volume effect, suggesting the presence of unmeasured confounding and overestimation of volume effects. However, the conclusions are limited in that only the number of included covariates was considered, but not the effect size of the non-included covariates.

The impact of gastrojejunostomy orientation on delayed gastric emptying after pancreaticoduodenectomy: a single center comparative analysis

BACKGROUND

Delayed gastric emptying (DGE) represents the most frequent complication after pancreaticoduodenectomy (PD). Aim of this study was to evaluate the impact of gastrojejunostomy (GJ)orientation on DGE incidence after PD.

METHODS

One-hundred and twenty-one consecutive PDs were included in the analysis and divided in the horizontal (H-GJ group) and vertical GJ anastomosis groups (V-GJ group). Postoperative data and the value of the flow angle between the efferent jejunal limb and the stomach of the GJ anastomosis at the upper gastrointestinal series were registered.

RESULTS

Seventy-five patients (62%)underwent H-GJ, while 46 patients (38%)underwent V-GJ. The incidence of DGE was significantly lower in the V-GJ group as compared to the H-GJ group (23.9%vs45.3%; p = 0.02). V-GJ was also associated to a less severe DGE manifestation (p = 0.006). The flow angle was significantly lower in case of V-GJ as compared to H-GJ (24.5°vs37°; p = 0.002). At the multivariate analysis, ASA score≥3 (p = 0.02), H-GJ (p = 0.03), flow angle>30°(p = 0.004) and Clavien-Dindo≥3 (p = 0.03) were recognized as independent prognostic factors for DGE. These same factors were independent prognostic features also for a more severe DGE manifestation.

CONCLUSION

VGJ and the more acute flow angle appear to be associated to a lower incidence rate and severity of DGE. This modified technique should be considered by surgeons in order to reduce postoperative DGE occurrence.

Somatostatin analogues for the prevention of pancreatic fistula after open pancreatoduodenectomy: A nationwide analysis

BACKGROUND

Somatostatin analogues (SA) are currently used to prevent postoperative pancreatic fistula (POPF) development. However, its use is controversial. This study investigated the effect of different SA protocols on the incidence of POPF after pancreatoduodenectomy in a nationwide population.

METHODS

All patients undergoing elective open pancreatoduodenectomy were included from the Dutch Pancreatic Cancer Audit (2014-2017). Patients were divided into six groups: no SA, octreotide, lanreotide, pasireotide, octreotide only in high-risk (HR) patients and lanreotide only in HR patients. Primary endpoint was POPF grade B/C. The updated alternative Fistula Risk Score was used to compare POPF rates across various risk scenarios.

RESULTS

1992 patients were included. Overall POPF rate was 13.1%. Lanreotide (10.0%), octreotide-HR (9.4%) and no protocol (12.7%) POPF rates were lower compared to the other protocols (varying from 15.1 to 19.1%, p = 0.001) in crude analysis. Sub-analysis in patients with HR of POPF showed a significantly lower rate of POPF when treated with lanreotide (10.0%) compared to no protocol, octreotide and pasireotide protocol (21.6-26.9%, p = 0.006). Octreotide-HR and lanreotide-HR protocol POPF rates were comparable to lanreotide protocol, however not significantly different from the other protocols. Multivariable regression analysis demonstrated lanreotide protocol to be positively associated with a low odds-ratio (OR) for POPF (OR 0.387, 95% CI 0.180-0.834, p = 0.015). In-hospital mortality rates were not affected.

CONCLUSION

Use of lanreotide in all patients undergoing pancreatoduodenectomy has a potential protective effect on POPF development. Protocols for HR patients only might be favorable too. However, future studies are warranted to confirm these findings.

Postoperative Outcomes Analysis After Pancreatic Duct Occlusion: A Safe Option to Treat the Pancreatic Stump After Pancreaticoduodenectomy in Low-Volume Centers

Background: Surgical resection is the only possible choice of treatment in several pancreatic disorders that included periampullar neoplasms. The development of a postoperative pancreatic fistula (POPF) is the main complication. Despite three different surgical strategies that have been proposed–pancreatojejunostomy (PJ), pancreatogastrostomy (PG), and pancreatic duct occlusion (DO)–none of them has been clearly validated to be superior. The aim of this study was to analyse the postoperative outcomes after DO.

Methods: We retrospectively reviewed 56 consecutive patients who underwent Whipple's procedure from January 2007 to December 2014 in a tertiary Hepatobiliary Surgery and Liver Transplant Unit. After pancreatic resection in open surgery, we performed DO of the Wirsung duct with Cyanoacrylate glue independently from the stump characteristics. The mean follow-up was 24.5 months.

Results: In total, 29 (60.4%) were men and 19 were (39.6%) women with a mean age of 62.79 (SD ± 10.02) years. Surgical indications were in 95% of cases malignant diseases. The incidence of POPF after DO was 31 (64.5%): 10 (20.8%) patients had a Grade A fistula, 18 (37.5%) Grade B fistula, and 3 (6.2%) Grade C fistula. No statistical differences were demonstrated in the development of POPF according to pancreatic duct diameter groups (p = 0.2145). Nevertheless, the POPF rate was significantly higher in the soft pancreatic group (p = 0.0164). The mean operative time was 358.12 min (SD ± 77.03, range: 221–480 min). Hospital stay was significantly longer in patients who developed POPF (p < 0.001). According to the Clavien-Dindo (CD) classification, seven of 48 (14.58%) patients were classified as CD III–IV. At the last follow-up, 27 of the 31 (87%) patients were alive.

Conclusions: Duct occlusion could be proposed as a safe alternative to pancreatic anastomosis especially in low-/medium-volume centers in selected cases at higher risk of clinically relevant POPF.

Exploring relationships between in-hospital mortality and hospital case volume using random forest: results of a cohort study based on a nationwide sample of German hospitals, 2016-2018

Background

Relationships between in-hospital mortality and case volume were investigated for various patient groups in many empirical studies with mixed results. Typically, those studies relied on (semi-)parametric statistical models like logistic regression. Those models impose strong assumptions on the functional form of the relationship between outcome and case volume. The aim of this study was to determine associations between in-hospital mortality and hospital case volume using random forest as a flexible, nonparametric machine learning method.

Methods

We analyzed a sample of 753,895 hospital cases with stroke, myocardial infarction, ventilation > 24 h, COPD, pneumonia, and colorectal cancer undergoing colorectal resection treated in 233 German hospitals over the period 2016–2018. We derived partial dependence functions from random forest estimates capturing the relationship between the patient-specific probability of in-hospital death and hospital case volume for each of the six considered patient groups.

Results

Across all patient groups, the smallest hospital volumes were consistently related to the highest predicted probabilities of in-hospital death. We found strong relationships between in-hospital mortality and hospital case volume for hospitals treating a (very) small number of cases. Slightly higher case volumes were associated with substantially lower mortality. The estimated relationships between in-hospital mortality and case volume were nonlinear and nonmonotonic.

Conclusion

Our analysis revealed strong relationships between in-hospital mortality and hospital case volume in hospitals treating a small number of cases. The nonlinearity and nonmonotonicity of the estimated relationships indicate that studies applying conventional statistical approaches like logistic regression should consider these relationships adequately.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07414-z.

Implementation of a regional reference center in pancreatic surgery. Experience after 631 procedures

INTRODUCTION

The main objective of this study is to determine whether our unit meets the quality standards required by the scientific community from the reference centers for pancreatic surgery in terms of peri-operative results. The secondary objectives are to compare the different pancreatic surgery techniques performed in terms of early post-operative morbidity and mortality and to analyze the impact of the resections added in these terms.

METHOD

Descriptive, retrospective and single-center study, corresponding to the period 2006-2019. The results obtained were compared with the proposed quality standards, by Bassi et al. and Sabater et al., required from the reference centers in pancreatic surgery. The sample was divided according to surgical technique and compared in terms of early post-operative morbidity and mortality, studying the impact of extended vascular and visceral resections. All patients undergoing pancreatic surgery in our unit due to pancreatic, malignant and benign pathology were included, since it was implemented as a reference center. Emergency procedures were excluded.

RESULTS

631 patients were analyzed. The values ​​obtained in the quality standards are in range. The most frequent surgery was pancreaticoduodenectomy, which associated higher peri-operative morbidity and mortality rates (P ≤ .05). The extended vascular resections impacted the pancreaticoduodenectomy group, associating a longer mean stay (P = .01) and a higher rate of re-interventions (P = .02).

CONCLUSIONS

The experience accumulated allows to meet the required quality standards, as well as perform extended resections to pancreatectomy with good results in terms of post-operative morbidity and mortality.

Improvement in Surgical Quality Following Pancreaticoduodenectomy With Increasing Case Volume in a Rural Hospital

BACKGROUND

The literature is replete with studies that define the nexus of quantity and quality in complex surgical operations. These observations have heralded a call for centralization of care to high-volume centers. The purpose of this study was to chronicle improvements in quality associated with pancreaticoduodenectomy (PD) as a rural hospital matures from a low- to very high-volume center.

METHODS

A retrospective review of a prospective pancreatic surgery database was undertaken from July 2007 to June 2020. Annual periods were characterized as low (≤12/year), high (13-29/year), and very high volume (≥30/year). Data for the following quality benchmarks were aggregated and compared: length of stay (LOS), 30-day readmissions, 30-day mortality, and 1- and 3-year survival. A subgroup analysis was undertaken in those patients undergoing PD for adenocarcinoma detailing margin status and number of lymph nodes harvested. Outcomes were compared using the Fisher's exact and Student's t-test.

RESULTS

375 PD were completed over the 13-year period; 62.1% were undertaken for ductal adenocarcinoma. There was a significant decrease in LOS and 30-day readmissions as the institution matured toward very high volume. There were no significant differences in 30-day mortality, 1- and 3-year survival, or margin negativity rates associated with volume. Extent of lymph node harvest significantly improved as institutional experience increased.

DISCUSSION

Our pancreatic surgery program matured rapidly from low to very high volume with institutional commitment and dedicated resources. As the institution matured, operational efficiencies and surgical quality improved. Not unexpectedly, biology trumped volume as reflected in 1- and 3-year survival rates.

Undertreatment of Pancreatic Cancer: The Intersection of Bias, Biology, and Geography

Pancreatic cancer is the third leading cause of cancer deaths in the United States. Black patients with pancreatic cancer experience higher incidence and increased mortality. Although racial biologic differences exist, socioeconomic status, insurance type, physician bias, and patient beliefs contribute to the disparities in outcomes observed among patients who are Black, indigenous, and people of color.

In-hospital survival after pancreatoduodenectomy is greater in high-volume hospitals versus lower-volume hospitals: a meta-analysis

BACKGROUND

Variation in cut-off values for what is considered a high volume (HV) hospital has made assessments of volume-outcome relationships for pancreaticoduodenectomy (PD) challenging. Accordingly, we performed a systematic review and meta-analysis comparing in-hospital mortality after PD in hospitals above and below HV thresholds of various cut-off values.

METHOD

PubMed/MEDLINE, Embase and Cochrane Library were searched to 4 January 2021 for studies comparing in-hospital mortality after PD in hospitals above and below defined HV thresholds. After data extraction, risk of bias was assessed using the Downs and Black checklist. A random-effects model was used for meta-analysis, including meta-regressions. Registration: PROSPERO, CRD42021224432.

RESULTS

From 1855 records, 17 observational studies of moderate quality were included. Median HV cut-off was 25 PDs/year (IQR: 20-32). Overall relative risk of in-hospital mortality was 0.37 (95% CI: 0.30, 0.45), that is, 63% less in HV hospitals. All subgroup analyses found an in-hospital survival benefit in performing PDs at HV hospitals. Meta-regressions from included studies found no statistically significant associations between relative risk of in-hospital mortality and region (USA vs. non-USA; p = 0.396); or 25th percentile (p = 0.231), median (p = 0.822) or 75th percentile (p = 0.469) HV cut-off values. Significant inverse relationships were found between PD hospital volume and other outcomes.

CONCLUSION

In-hospital survival was significantly greater for patients undergoing PDs at HV hospitals, regardless of HV cut-off value or region. Future research is required to investigate regions where low-volume centres have specialized PD infrastructure and the potential impact on mortality.

Re-defining a high volume center for pancreaticoduodenectomy

BACKGROUND

The purpose of this study was to re-evaluate the previously utilized definitions of high volume center for pancreaticoduodenectomy to determine/establish an objective, evidence based threshold of hospital volume associated with improvement in perioperative mortality.

METHODS

Patients who underwent pancreaticoduodenectomy were identified using the National Cancer Database from 2004 to 2015. The relationship between hospital volume and 90-day mortality was assessed using a logistic regression model. Receiver Operator Characteristic analysis was performed and Youden's statistic was utilized to calculate the optimal cut offs.

RESULTS

42,402 patients underwent elective Pancreaticoduodenectomy at 1238 unique hospitals. A logistic regression was performed which showed a significant inverse linear association between institutional volume and overall 90 day mortality. The maximum improvement in 90 day mortality is seen if the average annual hospital volume was greater than 9 (OR = 0.647 (0.595-0.702), p < 0.0001). When analysis is limited to hospitals that performed >9 cases per year, the maximum improvement in 90 day mortality was noticed at 36 cases per year (OR = 0.458 (0.399-0.525), p < 0.0001).

CONCLUSIONS

Based on our results, we recommend defining low, medium, and high volume centers for pancreaticoduodenectomy as hospitals with average annual volume less than 9, 9 to 35, and more than 35 cases per year, respectively.

The Relationship between Hospital Volume and In-Hospital Mortality of Severely Injured Patients in Dutch Level-1 Trauma Centers

Centralization of trauma centers leads to a higher hospital volume of severely injured patients (Injury Severity Score (ISS) > 15), but the effect of volume on outcome remains unclear. The aim of this study was to determine the association between hospital volume of severely injured patients and in-hospital mortality in Dutch Level-1 trauma centers. A retrospective observational cohort study was performed using the Dutch trauma registry. All severely injured adults (ISS > 15) admitted to a Level-1 trauma center between 2015 and 2018 were included. The effect of hospital volume on in-hospital mortality was analyzed with random effects logistic regression models with a random intercept for Level-1 trauma center, adjusted for important demographic and injury characteristics. A total of 11,917 severely injured patients from 13 Dutch Level-1 trauma centers was included in this study. Hospital volume varied from 120 to 410 severely injured patients per year. Observed mortality rates varied between 12% and 24% per center. After case-mix correction, no statistically significant differences between low- and high-volume centers were demonstrated (adjusted odds ratio 0.97 per 50 extra patients per year, 95% Confidence Interval 0.90–1.04, p = 0.44). The variation in hospital volume of the included Level-1 trauma centers was not associated with the outcome of severely injured patients. Our results suggest that well-organized trauma centers with a similar organization of care could potentially achieve comparable outcomes.

National Population Study of the Effect of Structure and Process on Outcomes of Digit Replantation

BACKGROUND

Surgeon experience, hospital volume, and teaching hospital status may play a role in the success of digit replantation. This study aims to analyze factors that influence digit replantation success rates.

STUDY DESIGN

We examined patients with traumatic digit amputations, between 2000 and 2015, from the National Health Insurance Research Database (NHIRD) of Taiwan, which comprises data of more than 99% of its population. We measured the number of traumatic digit amputations and success rate of replantation. Chi-square and ANOVA tests were used for descriptive statistics. Regression models were built to analyze the association among patient, surgeon, and hospital characteristics, and replant success.

RESULTS

We identified 13,416 digit replantation patients using the eligibility criteria. The overall replantation failure rate was significantly higher in medium- and high-volume hospitals (low-volume: 11%, medium-volume: 17%, and high-volume: 15%, p < 0.001). Teaching hospitals had significantly higher replantation failure rates [(15.5% vs 7.6%), odds ratio (OR) 2.0; confidence interval (CI) 1.1-3.7]. Lower surgeon case volume resulted in a significantly higher failure rate in the thumb replantation (OR 0.89; CI 0.85-0.94).

CONCLUSIONS

Teaching hospitals had greater odds of replantation failure, owing to being high volume centers and attempting more replantations. However, the effect of residents performing the replantation during their training should be considered. Teaching units are mandatory for resident training; however, a balance should be established to provide training, but with sufficient supervision to achieve optimal replant success. A national protocol to triage digit amputation cases to high volume centers with experienced microsurgeons will help improve the replantation success rate.

Surgeon experience contributes to improved outcomes in pancreatoduodenectomies at high risk for fistula development

BACKGROUND

Pancreatoduodenectomies at high risk for clinically relevant pancreatic fistula are uncommon, yet intimidating, situations. In such scenarios, the impact of individual surgeon experience on outcomes is poorly understood.

METHODS

The fistula risk score was applied to identify high-risk patients (fistula risk score 7-10) from 7,706 pancreatoduodenectomies performed at 18 international institutions (2003-2020). For each case, surgeon pancreatoduodenectomy career volume and years of practice were linked to intraoperative fistula mitigation strategy adoption and outcomes. Consequently, best operative approaches for clinically relevant pancreatic fistula prevention and best performer profiles were identified through multivariable analysis models.

RESULTS

Eight hundred and thirty high-risk pancreatoduodenectomies, performed by 64 surgeons, displayed an overall clinically relevant pancreatic fistula rate of 33.7%. Clinically relevant pancreatic fistula rates decreased with escalating surgeon career pancreatoduodenectomy (-49.7%) and career length (-41.2%; both P < .001), as did transfusion and reoperation rates, postoperative morbidity index, and duration of stay. Great experience (≥400 pancreatoduodenectomies performed or ≥21-year-long career) was a significant predictor of clinically relevant pancreatic fistula prevention (odds ratio 0.52, 95% confidence interval 0.35-0.76) and was more often associated with pancreatojejunostomy reconstruction and prophylactic octreotide omission, which were both independently associated with clinically relevant pancreatic fistula reduction. A risk-adjusted performance analysis also correlated with experience. Moreover, minimizing blood loss (≤400 mL) significantly contributed to clinically relevant pancreatic fistula prevention (odds ratio 0.40, 95% confidence interval 0.22-0.74).

CONCLUSION

Surgeon experience is a key contributor to achieve better outcomes after high-risk pancreatoduodenectomy. Surgeons can improve their performance in these challenging situations by employing pancreatojejunostomy reconstruction, omitting prophylactic octreotide, and minimizing blood loss.

Outcomes of Complex Gastrointestinal Cancer Resection at US News & World Report Top-Ranked vs Non-Ranked Hospitals

BACKGROUND

The US News & World Report (USNWR) annual ranking of the best hospitals for gastroenterology and gastrointestinal surgery offers direction to patients and healthcare providers, especially for recommendations on complex medical and surgical gastrointestinal (GI) conditions. The objective of this study was to examine the outcomes of complex GI cancer resections performed at USNWR top-ranked, compared to non-ranked, hospitals.

STUDY DESIGN

Using the Vizient database, data for patients who underwent esophagectomy, gastrectomy, and pancreatectomy for malignancy between January and December 2018 were reviewed. Perioperative outcomes were analyzed according to USNWR rank status. Primary outcome was in-hospital mortality. Secondary outcomes include length of stay, mortality index (observed-to-expected mortality ratio), rate of serious complication, and cost. Secondary analysis was performed for outcomes of patients who developed serious complications.

RESULTS

There were 3,054 complex GI cancer resections performed at 42 top-ranked hospitals vs 3,608 resections performed at 198 non-ranked hospitals. The mean annual case volume was 73 cases at top-ranked hospitals compared to 18 cases at non-ranked hospitals. Compared with non-ranked hospitals, top-ranked hospitals had lower in-hospital mortality (0.96% vs 2.26%, respectively, p < 0.001) and lower mortality index (0.71 vs 1.53, respectively). There were no significant differences in length of stay, rate of serious complications, or direct cost between groups. In patients who developed serious morbidity, top-ranked hospitals had a lower mortality compared with non-ranked hospitals (8.2% vs 16.8%, respectively, p < 0.01).

CONCLUSIONS

Within the context of complex GI cancer resection, USNWR top-ranked hospitals performed a 4-fold higher case volume and were associated with improved outcomes. Patients with complex GI-related malignancies may benefit from seeking surgical care at high-volume regional USNWR top-ranked hospitals.

Identifying the Optimal case-volume threshold for pancreatectomy in contemporary practice

BACKGROUND

The volume-mortality association led to regionalization recommendations for pancreatic surgery. Mortality following pancreatectomy has declined, but case-volume thresholds remain unchanged.

METHODS

Patients undergoing pancreatectomy from 2004 to 2013 were identified in the National Cancer Database (NCDB). Hospitals were divided into low (LV), medium (MV), and high-volume (HV) strata using 30-day mortality quartiles and logistic regression with cubic splines. Adjusted absolute difference and odds of 30-day mortality between strata were calculated.

RESULTS

Annual volumes for LV, MV, and HV were <4, 4-18 and > 18 cases using quartiles and <6, 6-18 and > 18 using cubic splines. Absolute 30-day mortality trended downwards, with differential improvements for MV and LV. Benchmark 30-day mortality for hospitals with >18 cases was 2.8%. For this benchmark, the case-volume threshold decreased from 31 in 2004 to 6 in 2013.

CONCLUSION

Differential improvement in 30-day mortality at LV and MV hospitals led to similar 30-day mortality odds at MV and HV hospitals by 2013.

Twelve Hundred Consecutive Pancreato-Duodenectomies from Single Centre: Impact of Centre of Excellence on Pancreatic Cancer Surgery Across India

BACKGROUND

Pancreato-duodenectomy (PD) is a technically challenging operation with significant morbidity and mortality. Over the period of time, Tata Memorial Centre has evolved into a high-volume centre for management of pancreatic cancer. Aim of this study is to report the short- and long-term outcomes of 1200 consecutive PDs performed at single tertiary cancer centre in India.

METHODS

1200 PDs were performed from 1992 to 2017. Prospectively maintained database was used to retrospectively assess the short- and long-term outcomes.

RESULTS

Study cohort was divided into periods A and B (500 and 700 patients, respectively). Both groups were comparable for demographic variables. Overall morbidity and mortality in entire cohort were 31.2% and 3.9%, respectively. Period B documented significant reduction in post-operative mortality (5.4% vs 2.8%), post-pancreatectomy haemorrhage (5.8% vs 3%) and bile leaks (3.4% vs 1.3%). However, incidence of delayed gastric emptying and clinically relevant post-operative pancreatic fistula was higher in period B. With median follow-up of 25 months, 3-year overall survival and disease-free survival for patients with pancreatic cancer were 43.7% and 38.7%, respectively, and that for periampullary tumours were 65.9% and 59.4%, respectively. Period B also corresponded with dissemination of technical expertise across diverse regions of India with specialised training of 35 surgeons.

CONCLUSION

Our study demonstrates the feasibility of delivering high-quality care in a dedicated high-volume centre even in a country with low incidence of pancreatic cancer with marked disparities in medical care and socio-economic conditions. Improved outcomes underscore the need to promote regionalisation via a dedicated training programme.

Facility volume-survival relationship in patients with early-stage pancreatic adenocarcinoma treated with neoadjuvant chemotherapy followed by pancreatoduodenectomy

BACKGROUND

There is evidence that neoadjuvant therapy is associated with improved survival compared with upfront pancreatectomy for pancreatic adenocarcinoma. Treatment at high-volume pancreatic surgery centers is associated with improved short-term postoperative outcomes compared with low-volume centers. We compared overall survival of patients with early-stage pancreatic adenocarcinoma who received neoadjuvant therapy before resection stratified by facility volume.

METHODS

Patients with clinical T0 to T2 pancreatic adenocarcinoma who received neoadjuvant therapy before pancreatoduodenectomy were identified in the National Cancer Database (2010-2016). High-volume pancreatic surgery centers performed ≥36 pancreatectomies/year. Patients were matched 1:1 by propensity score. Pathologic outcomes, postoperative outcomes, and overall survival were compared.

RESULTS

Before matching, 1,449 patients were treated at low-volume centers and 250 at high-volume pancreatic surgery centers. After matching, there were 177 patients per group. High-volume pancreatic surgery centers were more commonly academic/research facilities (99.4% vs 54.0%; P < .001), and patients traveled greater distances (65 vs 13 miles; P < .001). Time from diagnosis to neoadjuvant therapy and surgery was similar. Treatment at high-volume pancreatic surgery centers was associated with shorter duration of stay (7 vs 8 days; P = .003) and lower 90-day mortality rate after pancreatoduodenectomy (0.0% vs 5.0%; P = .01). Patients treated at high-volume pancreatic surgery centers had improved overall survival (36.3 vs 29.4 months; P = .03; hazard ratio 0.73). On subset analysis of academic/research facilities, high-volume pancreatic surgery centers remained associated with shorter duration of stay, lower 90-day mortality, and greater overall survival.

CONCLUSION

The majority of patients treated with neoadjuvant therapy for early-stage pancreatic adenocarcinoma received care at low-volume centers. Treatment at high-volume pancreatic surgery centers was associated with improved overall survival and short-term postoperative outcomes.

Laparoscopic partial hepatectomy is cost-effective when performed in high volume centers: A five state analysis

BACKGROUND

Prior studies comparing the efficacy of laparoscopic (LHR) and open hepatic resection (OHR) have not evaluated inpatient costs.

METHODS

We conducted a retrospective cohort study using the Healthcare Cost and Utilization Project State Inpatient Databases to identify patients undergoing hepatic resection between 2010 and 2014.

RESULTS

10,239 patients underwent hepatic resection. 865 (8%) underwent LHR and 9374 (92%) underwent OHR. On adjusting for hospital volume, patients undergoing LHR had a lower risk of respiratory (OR 0.64, 95% CI [0.52, 0.78]), wound (OR 0.48; 95% CI [0.29, 0.79]) and hematologic (OR 0.57; 95% CI [0.44, 0.73]) complication as well as a lower risk of being in the highest quartile of cost (0.58; 95% CI [0.43, 0.77]) than those undergoing OHR. Patients undergoing LHR in very high volume (>314 hepatectomies/year) centers had lower risk-adjusted 90-day aggregate costs of care than those undergoing OHR (-$8022; 95% CI [-$11,732, -$4311).

DISCUSSION

Laparoscopic partial hepatectomy is associated with lower risk of postoperative complication than OHR. This translates to lower aggregate costs in very high-volume centers.

Regionalization of trauma care by operative experience: Does the volume of emergent laparotomy matter?

INTRODUCTION

The volume-outcome relationship led to the regionalization of trauma care. The relationship between trauma centers' injury-specific laparotomy volume and outcomes has not been explored. The aim of our study was to examine the relationship between a trauma center's injury-specific laparotomy volume and outcomes in blunt and penetrating trauma patients.

METHODS

We performed a (2017) analysis of the Trauma Quality Improvement Program database. We included adult (age, ≥18 years) blunt and penetrating trauma patients who required emergent laparotomies for hemorrhage control. Trauma centers were stratified based on their blunt and penetrating laparotomy volumes: high volume (HV), ≥25 cases per year; medium volume (MV), 13 to 24 cases per year; and low volume (LV), ≤12 cases per year. Multivariate regression analysis was performed to explore predictors of in-hospital mortality.

RESULTS

A total of 8,588 patients underwent emergent laparotomy for either blunt (4,936; 57.5%) or penetrating injuries (3,652; 42.5%). Overall, mean ± SD age was 40 ± 17 years, abdomen Abbreviated Injury Scale was 3 (2-4), and Injury Severity Score was 26 (17-35). For American College of Surgeons (ACS) level I centers, 50% were HV; 29%, MV; and 21%, LV. For ACS level II centers, 7% were HV; 23%, MV; and 70%, LV. For ACS level III centers, 100% were LV. On multivariate regression analysis, admission of blunt and penetrating trauma patients to HV blunt and HV penetrating centers, respectively, was independently associated with improved in-hospital mortality. High-volume blunt centers had a significantly lower time to laparotomy (72 [41-144] minutes) versus MV (81 [49-145] minutes) and LV (94 [56-158] minutes) centers (p < 0.001). The same trend was observed for HV penetrating trauma centers (35 [24-52] minutes) versus MV (46 [33-63] minutes) and LV (51 [38-69] minutes) centers (p < 0.001).

CONCLUSION

Blunt and penetrating injury patients requiring emergent laparotomy had higher survival when admitted to trauma centers with HV operative experience for their particular mechanism of injury. The regionalization of trauma care should be based on a thorough evaluation of trauma centers' injury-specific operative experience.

LEVEL OF EVIDENCE

Prognostic, Level III; Therapeutic/Care management, Level IV.

Implementation of a regional reference center in pancreatic surgery. Experience after 631 procedures

INTRODUCTION

The main objective of this study is to determine if our unit meets the quality standards required by the scientific community from the reference centers for pancreatic surgery in terms of peri-operative results. The secondary objectives are to compare the different pancreatic surgery techniques performed in terms of early post-operative morbidity and mortality and to analyze the impact of the resections added in these terms.

METHOD

Descriptive, retrospective and single-center study, corresponding to the period 2006-2019. The results obtained were compared with the proposed quality standards, by Bassi et al. and Sabater et al., required from the reference centers in pancreatic surgery. The sample was divided according to surgical technique and compared in terms of early post-operative morbidity and mortality, studying the impact of extended vascular and visceral resections. All patients undergoing pancreatic surgery in our unit due to pancreatic, malignant and benign pathology were included, since it was implemented as a reference center. Emergency procedures were excluded.

RESULTS

631 patients were analyzed. The values ??obtained in the quality standards are in range. The most frequent surgery was cephalic duodenopancreatectomy, which associated higher peri-operative morbidity and mortality rates (p ≤ 0.05). The extended vascular resections impacted the cephalic duodenopancreatectomy group, associating a longer mean stay (p = 0.01) and a higher rate of re-interventions (p = 0.02).

CONCLUSIONS

The experience accumulated allows to meet the required quality standards, as well as perform extended resections to pancreatectomy with good results in terms of post-operative morbi-mortality.

Somatostatin administration following pancreatoduodenectomy: a case-matched comparison according to surgical technique, body mass index, American Society of Anesthesiologists' score and Fistula Risk Score

PURPOSE

This study evaluated the controversial role of somatostatin after pancreatoduodenectomy (PD), stratifying patients for the main risk factors using the most recent postoperative pancreatic fistula (POPF) classification and including only patients who had undergone PD with the same technique of pancreatojejunostomy.

METHODS

Between November 2010 and February 2020, 218 PD procedures were carried out via personal modified pancreatojejunostomy (mPJ-PD). Somatostatin was routinely administered between 2010 and 2016, while from 2017, 97 mPJ-PD procedures without somatostatin (WS) were performed. The WS group was retrospectively compared with a control (C) group obtained with one-to-one case-control matching according to the body mass index, American Society of Anesthesiologists' score, and Fistula Risk Score (FRS).

RESULTS

A total of 144 patients (72 WS group versus 72 C group) were compared. In the WS group. 6 patients (8.3%) developed clinically relevant POPF, compared with 8 patients (11.1%) in the C group (p = 0.656). In addition, on analyzing the subgroup of high-risk patients according to the FRS, we did not note any significant differences in POPF occurrence. Furthermore, no marked differences in the morbidity or mortality were found. Digestive bleeding and diabetes onset rates were higher in the WS group than in the control group, but not significantly so.

CONCLUSIONS

The results of the present study confirm no benefit with the routine administration of somatostatin after PD to prevent POPF, even in high-risk patients. However, a possible role in the prevention of postoperative digestive bleeding and diabetes was observed.

Effects of pancreatic resection for benign pancreatic neoplasms on pancreatic volume and endocrine function: A long-term computed tomography-based study

BACKGROUND

Pancreatic surgery may result in changes in pancreatic volume and endocrine function. The effects of pancreatic resection for benign neoplasms on pancreatic volume and endocrine function have not been established yet. This study aimed to investigate the long-term results of different pancreatic surgeries for benign pancreatic neoplasms on pancreatic volume and endocrine function.

METHODS

The medical records of 30 patients who underwent pancreaticoduodenectomy (PD) and 30 patients who underwent left-sided pancreatectomy(LP) for benign pancreatic neoplasms between 2005 and 2012 were reviewed. The changes in pancreatic volume after pancreatic surgery were assessed using multi-detector row computed tomography volumetry. Endocrine pancreatic function was evaluated on the basis of fasting glucose level or oral glucose tolerance test result.

RESULTS

The median follow-up duration was 91.3 months (interquartile range, 75.7-119.1 months). Reduction in pancreatic volume after surgery was more pronounced in patients who underwent PD than in those who underwent LP (median percentage of volume reduction, 23.8% vs 5.1%, p < .001). Multivariable analysis of prognostic factors for endocrine insufficiency showed that PD to be significant factor. (HR 3.87, 95% CI 1.12-14.66, p = .037).

CONCLUSIONS

The surgical methods for benign pancreatic neoplasms affect the reduction in pancreatic volume. Furthermore, the methods of pancreatic surgery were associated with the risk of endocrine insufficiency. Further studies with a large number of patients are warranted to evaluate the association between the degree of volume reduction and the development of endocrine insufficiency.

Do high-volume centers mitigate complication risk and reduce costs associated with performing pancreaticoduodenectomy in ethnic minorities?

INTRODUCTION

Few studies examine the impact of ethnicity on post-operative outcomes and costs associated with pancreaticoduodenectomy (PD).

METHODS

Multivariable regression (MVR) was used to perform a risk-adjusted comparison of patients within the Healthcare Cost and Utilization Project Databases undergoing PD.

RESULTS

4742 patients underwent PD. 3871 (81%) were white, 456 (10%) black, and 415 (9%) Hispanic. Black and Hispanics were less likely than whites to undergo PD in high volume centers. Blacks and Hispanics had a higher risk of select post-operative complications, prolonged lengths of stay, and high-cost outliers. When PDs done in high volume centers were evaluated separately, blacks and Hispanics had a lower adjusted-risk of any serious morbidity (OR 0.44, 95% CI [0.33, 0.57], OR 0.56, 95% CI [0.43, 0.73]) than whites but costs for PD among the three ethnic groups were statistically identical.

CONCLUSION

Racial and ethnic minorities undergoing PD are less likely to receive care at high-volume centers, are at an increased risk of post-operative morbidity, and have higher odds of being high-cost outliers than NHW.

Navigating by Stars: Using CMS Star Ratings to Choose Hospitals for Complex Cancer Surgery

Background

The Centers for Medicare and Medicaid Services (CMS) developed risk-adjusted “Star Ratings,” which serve as a guide for patients to compare hospital quality (1 star = lowest, 5 stars = highest). Although star ratings are not based on surgical care, for many procedures, surgical outcomes are concordant with star ratings. In an effort to address variability in hospital mortality after complex cancer surgery, the use of CMS Star Ratings to identify the safest hospitals was evaluated.

Methods

Patients older than 65 years of age who underwent complex cancer surgery (lobectomy, colectomy, gastrectomy, esophagectomy, pancreaticoduodenectomy) were evaluated in CMS Medicare Provider Analysis and Review files (2013-2016). The impact of reassignment was modeled by applying adjusted mortality rates of patients treated at 5-star hospitals to those at 1-star hospitals (Peters-Belson method).

Results

There were 105 823 patients who underwent surgery at 3146 hospitals. The 90-day mortality decreased with increasing star rating (1 star = 10.4%, 95% confidence interval [CI] = 9.8% to 11.1%; and 5 stars = 6.4%, 95% CI = 6.0% to 6.8%). Reassignment of patients from 1-star to 5-star hospitals (7.8% of patients) was predicted to save 84 Medicare beneficiaries each year. This impact varied by procedure (colectomy = 47 lives per year; gastrectomy = 5 lives per year). Overall, 2189 patients would have to change hospitals each year to improve outcomes (26 patients moved to save 1 life).

Conclusions

Mortality after complex cancer surgery is associated with CMS Star Rating. However, the use of CMS Star Ratings by patients to identify the safest hospitals for cancer surgery would be relatively inefficient and of only modest impact.

The impact of hospital, surgeon, and patient characteristics on digit replantation decision: A national population study

BACKGROUND

Traumatic finger amputations cause a substantial burden to health care system. The purpose of this study is to investigate the epidemiology of traumatic finger amputations, the incidence of replantation attempts and to examine the patient, surgeon, and hospital characteristics that were associated with replantation attempts.

METHODS

We examined 49,469 patients with traumatic digit amputations from the National Health Insurance Research Database (NHIRD) of Taiwan. We used Chi-square, ANOVA tests, and regression analysis to determine the important factors in decision to replant.

RESULTS

The replantation rate increased significantly with increased hospital volume (low-volume: 4.7%, medium-volume: 19.1 % and high-volume: 35.9 %). Regional hospitals were more likely to attempt replantation (odds ratio = 1.35). Low-volume hospitals had a replantation failure rate of 11.1 %, medium-volume 19.7 % and high-volume hospitals had 13.8 %.

CONCLUSION

With the national health insurance coverage, hospital volume is a substantial factor to encourage microsurgical-trained staff to perform digit replantation when indicated. The findings from this study will support government initiatives to foster and reward regionalization centers with high to medium case volume of replants to manage this critical function restoring procedure.

Pancreatic cancer treatment: better, but a long way to go

Remarkable progress has been made in treating pancreatic cancer over the past century, including refinement of our surgical techniques and improvements in adjuvant and neoadjuvant therapies. Despite these advances, the incidence of pancreatic cancer is rising globally, and it remains a deadly disease. In this review, we highlight the historical perspectives of pancreatic cancer treatment and outline the areas of future advancement that will assist progression towards better outcomes. Areas of future advancement include improving prevention strategies and early detection, refining our molecular understanding of pancreatic cancer, identifying more effective systemic therapies, and improving quality of life and surgical outcomes. Furthermore, systems need to be put in place to ensure all patients with pancreatic cancer receive high quality care and are given the appropriate options and sequence of therapy. This is best achieved through multidisciplinary care.

Differences in Treatment of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis at Burn Centers and Nonburn Centers

Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and Stevens-Johnson/TEN overlap syndrome (SJS/TEN) are severe exfoliative skin disorders resulting primarily from allergic drug reactions and sometimes from viral causes. Because of the significant epidermal loss in many of these patients, many of them end up receiving treatment at a burn center for expertise in the care of large wounds. Previous work on the treatment of this disease focused only on the differences in care of the same patients treated at nonburn centers and then transferred to burn centers. We wanted to explore whether patients had any differences in care or outcomes when they received definitive treatment at burn centers and nonburn centers. We queried the National Inpatient Sample database from 2016 for patients with SJS, SJS/TEN, and TEN diagnoses. We considered burn centers as those with greater than 10 burn transfers to their center and fewer than 5 burn transfers out of their center in a year. Multivariable logistic regression assessed factors associated with treatment at a burn center and mortality. Using the National Inpatient Sample, a total of 1164 patients were identified. These were divided into two groups, nonburn centers vs burn centers, and those groups were compared for demographic characteristics as well as variables in their hospital course and outcome. Patients treated at nonburn centers were more likely to have SJS and patients treated at burn centers were more likely to have both SJS/TEN and TEN. Demographics were similar between treatment locations, though African-Americans were more likely to be treated at a burn center. Burn centers had higher rates of patients with extreme severity and mortality risks and a longer length of stay. However, burn centers had similar actual mortality compared to nonburn centers. Patients treated at burn centers had higher charges and were more likely to be transferred to long-term care after their hospital stay. The majority of patients with exfoliative skin disorders are still treated at nonburn centers. Patients with SJS/TEN and TEN were more likely to be treated at a burn center. Patients treated at burn centers appear to have more severe disease but similar mortality to those treated at nonburn centers. Further study is needed to determine whether patients with these disorders do indeed benefit from transfer to a burn center.

One-layer pancreaticojejunostomy using reinforcing sutures in pancreaticoduodenectomy: A single surgeon's experience with 122 cases

BACKGROUND

Discussions about pancreaticojejunostomy (PJ), which can reduce the incidence of postoperative pancreatic fistula (POPF) in pancreaticoduodenectomy (PD), are ongoing. Here we introduce the surgical technique of PJ performed at our hospital and analyze its safety and advantages.

METHODS

We retrospectively analyzed 122 patients who underwent one-layer PJ using reinforcing sutures in PD. PJ was performed with reinforcing sutures on the pancreatic stump, including the insertion of a soft silastic catheter for internal drainage followed by suturing of the pancreas and jejunum with one layer.

RESULTS

Of the 122 patients who underwent PJ with this technique, 62 (50.8%) developed POPF. However, 37 (30.3%) had grade A that did not affect the hospital course. Critical POPF occurred in 25 patients: grade B in 20 (16.4%) and grade C in 5 (4.1%). There was no significant difference in the critical POPF patient group according to the pancreas related disease related to pancreatic texture.

CONCLUSION

Although this technique cannot prevent POPF, we noted no significant difference in POPF versus other surgical techniques. In addition, this technique, which was designed to increase pancreatic texture, is practical and simple for PJ. Therefore, the inexperienced hepatobiliary and pancreatic surgeon can perform it without major complications.

National Trends in Readmission and Resource Utilization After Pancreatectomy in the United States

INTRODUCTION

Pancreatectomy is a complex operation that has been associated with excess morbidity and mortality. Although acute index outcomes have been characterized, there are limited data available on nonelective readmission after pancreatic surgery. We sought to identify factors associated with 30-day and 30- to 90-day readmission after pancreatectomy.

MATERIAL AND METHODS

We utilized the National Readmissions Database between 2010 and 2016 to identify adults who underwent a pancreatectomy. The primary outcomes were 30-day (30DR) and 30- to 90-day (90DR) readmission. Secondary outcomes included nonelective readmission trends, diagnosis, length of stay, charges, and mortality.

RESULTS

Of an estimated 130,267 subjects undergoing pancreatectomy, 97% survived index hospitalization. Eighteen percent of patients had nonelective 30DR while 5.6% experienced 90DR. Readmission at the two time points remained stable during the study period. After adjusting for institution, pancreatectomy volume, mortality (2.0% versus 4.9%, P < 0.001), 30DR length of stay (7.3 d versus 7.8 d, P < 0.001), and 90DR rates (6.9% versus 8.1%, P = 0.003) were significantly decreased at high-volume pancreatectomy centers compared to low-volume hospitals. Discharge to a skilled nursing facility (AOR: 1.52) or with home health care (AOR: 1.2) was associated with 30DR (P < 0.001). Patients undergoing total pancreatectomy (AOR: 1.3) or those with a substance use disorder (AOR: 1.4) among others were associated with 90DR (P ≤ 0.01).

CONCLUSIONS

Readmissions are common and costly after pancreatectomy. Approximately 20% of patients experience readmission within 30 d. 30DR and 90DR rates remained stable during the study. Pancreatectomy at a high-volume center was associated with decreased mortality and 90DR. The present analysis confirms associations between pancreatectomy volume, postsurgical complications, comorbidities, and readmission.

Impact of Diagnosing Urologists and Hospitals on the Use of Radical Cystectomy

Background

One out of five patients with muscle-invasive bladder cancer undergo radical cystectomy—a guideline-recommended treatment. Previous studies have primarily evaluated patient characteristics associated with the use of radical cystectomy, ignoring potential nesting of data.

Objective

To determine the impact of patient, diagnosing urologist, and hospital characteristics on the variation in the use of radical cystectomy.

Design, setting, and participants

This is a retrospective cohort study using the Surveillance, Epidemiology, and End Results Registry (SEER)-Medicare linked database.

Outcome measurements and statistical analysis

A total of 7097 muscle-invasive bladder cancer patients and 4601 diagnosing urologists affiliated to 822 hospitals from January 1, 2002 to December 31, 2012 were analyzed. Multilevel logistic regression analyses were used to determine variation and factors associated with the use of radical cystectomy.

Results and limitations

Of the 7097 patients, only 27% underwent radical cystectomy. The intraclass correlation coefficient for variation in the use of radical cystectomy attributed to the hospital level was 4.3%. Higher radical cystectomy volume by diagnosing urologists (more than five vs zero to one surgery: odds ratio [OR], 1.27; 95% confidence interval [CI], 1.00–1.62) and hospitals (more than five vs zero to four surgeries: OR,1.48; 95% CI, 1.14–1.93) was associated with increased use of radical cystectomy. Patients diagnosed by female rather than male urologists were more likely to undergo radical cystectomy (OR, 1.32; 95% CI, 1.07–1.62).

Conclusions

We found that 4.3% variation in the use of radical cystectomy was attributed to the hospital level, leaving 95.7% variation in use unexplained. We identified significantly increased use among higher-volume and female diagnosing urologists. These findings support further investigation into measures beyond hospital volume, which largely impact the utilization of radical cystectomy.

Patient summary

In this large population-based study, we found that 4.3% of variation in the use of radical cystectomy was attributed to the hospital level, leaving 95.7% variation in use unexplained. Higher radical cystectomy volume of diagnosing urologists and female urologists were independently associated with increased use of radical cystectomy. These findings support further investigation into measures beyond hospital volume, which largely impact the utilization of radical cystectomy.

The Impact of Regionalization of Pancreaticoduodenectomy for Pancreatic Cancer in North Carolina since 2004

Pancreaticoduodenectomy (PD) carries a significant risk. High-volume centers (HVCs) provide improved outcomes and regionalization is advocated. Rapid regionalization could, however, have detrimental effects. North Carolina has multiple HVCs, including an additional HVC added in late 2006. We investigated regionalization of PD and its effects before, and after, the establishment of this fourth HVC. The North Carolina Hospital Discharge Database was queried for all PDs performed during 2004 to 2006 and 2007 to 2009. Hospitals were categorized by PD volume as: low (one to nine/year), medium (10 to 19/year), and high (20/year or more). Mortality and major morbidity was assessed by comparing volume groups across time periods. Number of PDs for cancer increased 91 per cent (129 to 246 cases) at HVCs, whereas decreasing at low-volume (62 to 58 cases) and medium-volume (80 to 46 cases) centers. Percentage of PD for cancer performed at HVCs increased significantly (47.6 to 70.3%) while decreasing for low- and medium-volume centers ( P < 0.001). Mortality was significantly less at HVCs (2.8%) compared with low-volume centers (10.3%) for 2007 to 2009. Odds ratio for mortality was significantly lower at HVCs during 2004 to 2006 (0.31) and 2007 to 2009 (0.34). Mortality for PD performed for cancer decreased from 6.6 to 4.6 per cent ( P = 0.31). Major morbidity was not significantly different between groups within either time period; however, there was a significant increase in major morbidity at low-volume centers ( P = 0.018). Regionalization of PD for cancer is occurring in North Carolina. Mortality was significantly lower at HVCs, and rapid regionalization has not detracted from the superior outcomes at HVCs.

Laparoscopic Versus Open Pancreaticoduodenectomy: A Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVE

To compare perioperative outcomes of laparoscopic pancreaticoduodenectomy (LPD) to open pancreaticoduodenectomy (OPD) using evidence from randomized controlled trials (RCTs).

BACKGROUND

LPD is used more commonly, but this surge is mostly based on observational data.

METHODS

We searched CENTRAL, Medline and Web of Science for RCTs comparing minimally invasive to OPD for adults with benign or malignant disease requiring elective pancreaticoduodenectomy. Main outcomes were 90-day mortality, Clavien-Dindo ≥3 complications, and length of hospital stay (LOS). Secondary outcomes were postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), postpancreatectomy hemorrhage (PPH), bile leak, blood loss, reoperation, readmission, oncologic outcomes (R0-resection, lymph nodes harvested), and operative times. Data were pooled as odds ratio (OR) or mean difference (MD) with a random-effects model. Risk of bias was assessed using the Cochrane Tool and the GRADE approach (Prospero registration ID: CRD42019120363).

RESULTS

Three RCTs with a total of 224 patients were included. Meta-analysis showed there were no significant differences regarding 90-day mortality, Clavien-Dindo ≥3 complications, LOS, POPF, DGE, PPH, bile leak, reoperation, readmission, or oncologic outcomes between LPD and OPD. Operative times were significantly longer for LPD {MD [95% confidence interval (CI)] 95.44 minutes (24.06-166.81 minutes)}, whereas blood loss was lower for LPD [MD (CI) -150.99 mL (-168.54 to -133.44 mL)]. Certainty of evidence was moderate to very low.

CONCLUSIONS

At current level of evidence, LPD shows no advantage over OPD. Limitations include high risk of bias and moderate to very low certainty of evidence. Further studies should focus on patient safety during LPD learning curves and the potential role of robotic surgery.

The Impact of Radiotherapy Facility Volume on the Survival and Guideline Concordance of Patients With Muscle-invasive Bladder Cancer Receiving Bladder-preservation Therapy

OBJECTIVES

Higher facility surgical volume predicts for improved outcomes in patients with muscle-invasive bladder cancer (MIBC) who undergo radical cystectomy. We investigated the association between facility radiotherapy (RT) case volume and overall survival (OS) for patients with MIBC who received bladder-preserving RT, and the relationship with adherence to National Comprehensive Cancer Network (NCCN) guidelines for bladder preservation.

METHODS

The National Cancer Database was used to identify patients diagnosed with nonmetastatic MIBC from 2004 to 2015 and received RT at the reporting center. Facility case volume was defined as the total MIBC patients treated with RT during the period. Facilities were stratified into high-volume facility (HVF) or low-volume facility at the 80th percentile of RT case volume. OS was assessed using Kaplan-Meier analysis. Rates of compliance with NCCN guidelines regarding the use of transurethral resection of the bladder tumor before RT, planned use of concurrent chemotherapy, and total RT dose were compared. Cox proportional hazard model was used to evaluate predictors of OS.

RESULTS

There were 7562 patients included. No differences in age, Charlson-Deyo score, T stage, or node-positive rates were observed between groups. HVFs exhibited greater compliance with NCCN guidelines for bladder preservation (P<0.0001). Treatment at an HVF was associated with the improved OS for all patients (P=0.001) and for the subset of patients receiving NCCN-recommended RT doses (P=0.0081). Volume was an independent predictor of OS (P=0.002).

CONCLUSIONS

Treatment at an HVF is associated with improved OS and greater guideline-concordant management among patients with MIBC.

The volume-outcome relationship among severely injured patients admitted to English major trauma centres: a registry study

BACKGROUND

Many countries have centralized and dedicated trauma centres with high volumes of trauma patients. However, the volume-outcome relationship in severely injured patients (Injury Severity Score (ISS) > 15) remains unclear. The aim of this study was to determine the association between hospital volume and outcomes in Major Trauma Centres (MTCs).

METHODS

A retrospective observational cohort study was conducted using the Trauma Audit and Research Network (TARN) consisting of all English Major Trauma Centres (MTCs). Severely injured patients (ISS > 15) admitted to a MTC between 2013 and 2016 were included. The effect of hospital volume on outcome was analysed with random effects logistic regression models with a random intercept for centre and was tested for nonlinearity. Primary outcome was in-hospital mortality.

RESULTS

A total of 47,157 severely injured patients from 28 MTCs were included in this study. Hospital volume varied from 69 to 781 severely injured patients per year. There were small between-centre differences in mortality after adjusting for important demographic and injury severity characteristics (adjusted 95% odds ratio range: 0.99-1.01). Hospital volume was found to be linear and not associated with in-hospital mortality (adjusted odds ratio (aOR) 1.02 per 10 patients, 95% confidence interval (CI) 0.68-1.54, p = 0.92).

CONCLUSIONS

Despite the large variation in volume of the included MTCs, no relationship between hospital volume and outcome of severely injured patients was found. These results suggest that centres with similar structure and processes of care can achieve comparable outcomes in severely injured patients despite the number of severely injured patients they treat.