Hospital volume and mortality after pancreatic resection: a systematic review and an evaluation of intervention in the Netherlands

Use of textbook outcome as a quality metric in hepatopancreaticobiliary surgery: a systematic review and meta-analysis

BACKGROUND

Textbook outcomes (TOs) represent the optimal course after surgery. To date, no meta-analysis has assessed the pooled TOs of patients undergoing hepatopancreatobiliary (HPB) surgery and the effect of TO achievement on patient outcomes. This systematic review and meta-analysis aimed to assess TO achievement across different studies and to characterize the effect of TO achievement on patient-related outcomes, including disease-free survival (DFS) and overall survival (OS).

METHODS

PubMed, Embase, and Scopus databases were searched (1990-2024). The criteria used to define TO and the median overall TO in HPB surgery were obtained. In addition, a random-effects meta-analysis was conducted to assess the effect of TO achievement on 5-year OS and DFS.

RESULTS

A total of 27 studies involving 517,304 patients met inclusion criteria. The main criteria used to define TO included absence of readmission and mortality within 30 days after discharge, severe postoperative complications, prolonged hospital stay, and negative surgical margin (R0). Of note, the main factors related to TO achievement were younger patient age and lower American Society of Anesthesiologists score. Overall, the median rates of TOs achieved across procedures were 62.0% (IQR, 48.0%-69.0%) for hepatic procedure, 54.0% (IQR, 41.0%-68.0%) for biliary procedure, 46.0% (IQR, 42.0%-46.5%) for combined hepatopancreatic procedure, 45.0% (IQR, 30.5%-59.0%) for pancreatic procedure, 33.0% (IQR, 32.2%-34.0%) for liver transplantation, and 19.5% (IQR, 16.8%-22.3%) for combined hepatobiliary procedure. TO achievement was associated with improved odds of 5-year OS (odds ratio [OR], 1.22 [95% CI, 1.20-1.24]) and 5-year DFS (OR, 1.26 [95% CI, 1.16-1.37]).

CONCLUSION

Overall, hepatic and biliary operations had the highest TO achievement, followed by pancreatic procedures. In contrast, hepatobiliary surgery and liver transplantation had the lowest TO. There was a significant discrepancy in the definition of TO across different studies, highlighting the need for consensus on the definition of TO.

The association between hospital volume and overall survival in adult AML patients treated with intensive chemotherapy

BACKGROUND

Acute myeloid leukemia (AML) requires specialized care, particularly when administrating intensive remission induction chemotherapy (ICT). High-volume hospitals are presumed more adept at delivering this complex treatment, resulting in better overall survival (OS) rates. Despite its potential implications for quality improvement, research on the volume-outcome relationship in ICT administration for AML is scarce. This nationwide, population-based study in the Netherlands explored the volume-outcome relationship in AML.

MATERIALS AND METHODS

Data from the Netherlands Cancer Registry on adult (≥18 years of age) ICT-treated AML patients, diagnosed between 2014 and 2018, were analyzed. Hospital volume was assessed against OS using mixed-effects Cox regression, adjusting for patient and disease characteristics (i.e. case mix), with hospital as a random effect.

RESULTS

Our study population consisted of a total of 1761 patients (57% male), with a median age of 61 years. The average annual number of ICT-treated patients varied across the 24 hospitals (range 1-56, median 13, and interquartile range 8-20 patients per hospital per year). Overall, an increase of 10 ICT-treated patients annually was associated with an 8% lower mortality risk [hazard ratio (HR) 0.92, 95% confidence interval (CI) 0.87-0.98, P = 0.01]. This association was not significant at 30-day (HR 1.02, 95% CI 0.89-1.17, P = 0.75) and 42-day (HR 0.96, 95% CI 0.85-1.08, P = 0.54) OS but became apparent after 100-day OS (HR 0.91, 95% CI 0.83-0.99, P = 0.05).

CONCLUSIONS

There is a volume-outcome association within AML care. This finding could support hospital volume as a metric in AML care. However, it should be acknowledged that centralizing care is a complex process with implications for health care providers and patients. Therefore, any move toward centralization must be judiciously balanced.

Network Meta-Analysis and Trial Sequential Analysis of Randomised Controlled Trials Comparing Robotic, Laparoscopic, and Open Pancreatoduodenectomy

Background

The use of minimally invasive (laparoscopic and robotic) pancreatoduodenectomy (PD) is being increasingly adopted despite the lack of hard evidence to support its utilisation. With recent randomised controlled trials (RCTs) comparing open pancreatoduodenectomy (OPD) with robotic or laparoscopic pancreatoduodenectomy (RPD or LPD), we undertook a network meta-analysis (NMA) comparing all 3 approaches to evaluate comparative outcomes.

Methods

A systematic search of MEDLINE, EMBASE, and Cochrane CENTRAL was conducted up to May 2024 and relevant RCTs were identified. A random-effects meta-analysis and trial sequential analysis (TSA) were conducted for primary outcomes, followed by a Bayesian NMA of length of stay (LOS), duration of surgery, intraoperative blood loss, and pancreas resection-related outcomes.

Results

Seven RCTs involving 1336 patients were included, 5 investigating LPD compared with OPD and 2 RPD to OPD. Pairwise meta-analysis indicated that LPD was associated with shorter hospital stay (mean difference [MD], -1.39; 95% confidence interval [CI], -2.33 to -0.45) and lower intraoperative blood loss compared with OPD (MD, -131; 95% CI, -146 to -117). However, LPD was associated with significantly longer operative duration (MD, 39.5; 95% CI, 34-45). TSA confirmed the robustness of the positive and negative findings on pairwise meta-analysis. In comparison, there were no significant differences between RPD and OPD in pairwise meta-analysis, which could not be confirmed by TSA. Network meta-analysis tended to favour LPD in most outcome parameters including LOS, duration of surgery, and pancreas resection-related outcomes.

Conclusions

The current RCT evidence suggests potential better outcomes in LPD in comparison with RPD and OPD. However, few studies demonstrated robust statistical significance in outcome measures, suggesting an underpowered evidence base and possible selection bias. Hence, with current equivocal data, there is a need for ongoing RCTs to validate the role of minimally invasive approaches in PD.

A Self-Calibrating Fluorescent-Photoacoustic Integrated Probe Enables Fast Visualizing Pancreatic Cancer and Imaging-Guided Tumor Surgery

Pancreatic cancer is known for its high invasiveness and metastasis, making rapid visualization and precise treatment critical for improving patient outcomes. Current diagnostic tools lack abilities to provide rapid and accurate tumor localization, particularly for real-time intraoperative guidance. To address this gap, the study has developed a novel Förster Resonance Energy Transfer (FRET)-mediated dual-ratiometric near-infrared fluorescence (NIRF)/photoacoustic (PA) bimodal probe, SiRho-SHD-NTR, specifically designed for the fast and accurate navigation of pancreatic tumor resection. The probe, due to its excellent binding affinity with nitroreductase (NTR), can rapidly reach response saturation. Cellular experiments demonstrate that the probe rapidly and efficiently penetrates cancer cells, enhancing the effectiveness of PA imaging for preliminary diagnosis and tumor localization, while also enabling the rapid visualization of pancreatic tumors through NIRF imaging. Leveraging the rapid response characteristics of the probe to NTR, the study achieves precise tumor imaging in orthotopic pancreatic cancer mice by spraying the probe, within ≈5 min. More importantly, the probe even allows for the fast visualization of metastatic tumors and fluorescence-guided surgical resection. It is believed that SiRho-SHD-NTR will offer a promising method in the rapid visualization of pancreatic cancer and provide a powerful tool for imaging-guided tumor surgery, targeting both primary and metastatic tumors.

Impact of the thresholds of surgical volume on mortality in oncological digestive surgery: A French National Cohort

OBJECTIVE

To report the 90-day mortality benefit associated with the implementation of the new regulatory reform on oncological surgical digestive authorizations.

SUMMARY BACKGROUND DATA

New thresholds in digestive cancer surgery were applied in 2023, accrediting centers for major interventions. No evidence has been provided to support their justification.

METHODS

Any French adult operated for digestive cancer from January 1, 2019 to December 31, 2021 was included from the PMSI. A 90-day mortality logistic regression was performed by adjusting by age, sex, Charlson score, Frailty index, hospital-volume (<5 or ≥5 interventions/year), emergency intervention, specialty.

RESULTS

143,582 patients were identified. Of these, 64,268 underwent surgery of one of the subspecialties subject to the new thresholds (stomach N = 8283, liver N = 18,668, pancreas N = 11,220, esophagus N = 3704, rectum N = 22,393). 4808 (7.5 %) patients underwent surgery in low-volume centers, distributed as follows: stomach 1757/8283 (22.94 %), liver 970/18,668 (5.19 %), pancreas 895/11,220 (7.98 %), esophagus 672/3704 (18.14 %) and rectum 514/22,393 (2.29 %). In univariate analysis, the 90-day mortality rate was significantly lower in high-volume centers, for all subspecialties, gastric: 127/1757 (7.23 %) vs 330/6526 (5.06 %), p = 0.0004, hepatic: 64/970 (6.6 %) vs 824/17,698 (4.66 %), p = 0.006, pancreatic: 74/895 (8, 27 %) vs 608/10,325 (5.89 %), p = 0.004, esophageal: 58/672 (8.63 %) vs 195/3032 (6.43 %), p = 0.04, rectal 26/514 (5.06 %) vs 639/21,879 (2.92 %), p = 0.005. The multivariate analysis, showed a mortality reduction for high-volume centers: OR = 0.78 CI95[0.71-0.87], p < 0.001.

CONCLUSION

The recent implementation of regulatory decrees appears to be justified. The enforcement of these hospital volume thresholds is likely to contribute to a reduction in postoperative mortality following digestive cancer surgery.

Comparing oncologic and surgical outcomes of robotic and laparoscopic distal pancreatectomy: a propensity-matched analysis

BACKGROUND

The frequency of minimally invasive distal pancreatectomy is gradually exceeding that of the open approach. Our study aims to compare short-term outcomes of robotic (RDP) and laparoscopic (LDP) distal pancreatectomies for pancreatic ductal adenocarcinoma (PDAC) using a national database.

METHODS

The National Cancer Database was utilized to identify patients with PDAC who underwent distal pancreatectomy from 2010-2020. Short-term technical and oncologic outcomes such as margin status and nodal harvest were included. Propensity-score matching (PSM) was performed comparing LDP and RDP cohorts. Multivariate logistic-regression models were then used to assess the impact of institutional volume on the MIDP surgical and technical oncologic outcomes.

RESULTS

1537 patients underwent MIDP with curative intent. Most cases were laparoscopic (74.4%, n = 1144), with a gradual increase in robotic utilization, from 8.7% in 2010 to 32.0% of MIDP cases ten years later. For PSM, 698 LDP patients were matched with 349 RDP. The odds of conversion to an open case were 58% less in RDP (12.6%) compared to LDP (25.5%) with no statistically significant difference in technical oncologic results. There was no difference in length of stay (OR = 1.0[0.7-1.4]), 30-day mortality (OR = 0.5[0.2-2.0]) or 90-day mortality (OR = 1.1[0.5-2.4]) between RDP and LDP, although there was a higher 30-day readmission rate with RDP (OR = 1.71[1.1-2.7]). There were statistically significant differences in technical oncologic outcomes (nodal harvest, margin status, initiation of adjuvant therapy) based on MIDP volume quartiles.

CONCLUSION

Laparoscopic and robotic distal pancreatectomy have similar peri- and post-operative surgical and oncologic outcomes, with a higher rate of conversion to open in the laparoscopic cohort.

Laparoscopic distal pancreatectomy for pancreatic cancer: an overview of evaluation and treatment strategies

Background

Laparoscopic distal pancreatectomies (LDP) confer benefits over open distal pancreatectomies (ODP). These benefits extend to patients with known malignancies. Despite being a common procedure for pancreatic surgeons, widespread adoption of minimally invasive approaches is still not universal. Improved understanding of the benefits of LDP as well as operative steps can help further spread the use of minimally invasive techniques.

Methods

The authors present their approach to LDP with an emphasis on anatomy, intraoperative technique, and pearls/pitfalls. A brief historical overview of the development of LDP and landmark studies is also included.

Results

Review of milestones along the evolution of LDP are presented, showcasing the controversies and advantages that are associated with the procedure. Current perspectives and society recommendations are also discussed. Operative steps of LDP are described via the "clockwise technique". This technique outlines a step-wise method that includes wide mobilization for adequate exposure, slow compression of pancreatic parenchyma, and other important pearls such as patient positioning and operative planning.

Conclusions

Proper understanding of LDP is crucial to maximizing positive outcomes from the operation. Further education on technical pearls can help increase use of minimally invasive approaches to distal pancreatic resection for cancer.

Centralization of Pancreaticoduodenectomy: A Systematic Review and Spline Regression Analysis to Recommend Minimum Volume for a Specialist Pancreas Service

OBJECTIVE

Through a systematic review and spline curve analysis, to better define the minimum volume threshold for hospitals to perform (pancreaticoduodenectomy) and the high-volume center.

BACKGROUND

The pancreaticoduodenectomy (PD) is a resource-intensive procedure, with high morbidity and long hospital stays resulting in centralization towards high-volume hospitals; the published definition of high volume remains variable.

MATERIALS AND METHODS

Following a systematic review of studies comparing PD outcomes across volume groups, semiparametric regression modeling of morbidity (%), mortality (%), length of stay (days), lymph node harvest (number of nodes), and cost ($USD) as continuous variables were performed and fitted as a smoothed function of splines. If this showed a nonlinear association, then a "zero-crossing" technique was used, which produced "first and second derivatives" to identify volume thresholds.

RESULTS

Our analysis of 33 cohort studies (198,377 patients) showed 55 PDs/year and 43 PDs/year were the threshold value required to achieve the lowest morbidity and highest lymph node harvest, with model estimated df 5.154 ( P <0.001) and 8.254 ( P <0.001), respectively. The threshold value for mortality was ~45 PDs/year (model 9.219 ( P <0.001)), with the lowest mortality value (the optimum value) at ~70 PDs/year (ie, a high-volume center). No significant association was observed for cost ( edf =2, P =0.989) and length of stay ( edf =2.04, P =0.099).

CONCLUSIONS

There is a significant benefit from the centralization of PD, with 55 PDs/year and 43 PDs/year as the threshold value required to achieve the lowest morbidity and highest lymph node harvest, respectively. To achieve mortality benefit, the minimum procedure threshold is 45 PDs/year, with the lowest and optimum mortality value (ie, a high-volume center) at approximately 70 PDs/year.

Requirements for hospitals in Japan to have low operative mortality and failure-to-rescue rates

Aim

We explored institutional factors in Japan associated with lower operative mortality and failure-to-rescue (FTR) rates for eight major gastrointestinal procedures.

Methods

A 22-item online questionnaire was sent to 2119 institutional departments (IDs) to examine the association between institutional factors and operative mortality and FTR rates. IDs were classified according to the number of annual surgeries, board certification status, and locality. In addition, the top 20% and bottom 20% of IDs were identified based on FTR rates and matched with the results of the questionnaire survey. Factors associated with operative mortality were selected by multivariate analysis.

Results

Of the 1083 IDs that responded to the questionnaire, 568 (213 382 patients) were included in the analysis. Operative morbidity, operative mortality, and FTR rates in the top 20% and bottom 20% of IDs were 13.1% and 8.4% (p < 0.001), 0.52% and 4.3% (p < 0.001), and 4.0% and 51.2% (p < 0.001), respectively. Based on the patients' background characteristics, the top 20% of IDs handled more advanced cases. No significant difference in locality was seen between better or worse hospital FTR rates, but fewer esophagectomies, hepatectomies, and pancreatoduodenectomies were performed in depopulated areas. Six items were found to be associated with operative mortality by multivariate logistic analysis. Only 50 (8.8%) IDs met all five factors related to better FTR rates.

Conclusions

The present findings indicate that several hospital factors surrounding surgical treatment, characterized by abundant human resources, are closely related to better postoperative recovery from severe complications.

The Need for Centralization for Small Intestinal Neuroendocrine Tumor Surgery: A Cohort Study from the GTE-Endocan-RENATEN Network, the CentralChirSINET Study

BACKGROUND

The concept of surgical centralization is becoming more and more accepted for specific surgical procedures.

OBJECTIVE

The aim of this study was to evaluate the relationship between procedure volume and the outcomes of surgical small intestine (SI) neuroendocrine tumor (NET) resections.

METHODS

We conducted a retrospective national study that included patients who underwent SI-NET resection between 2019 and 2021. A high-volume center (hvC) was defined as a center that performed more than five SI-NET resections per year. The quality of the surgical resections was evaluated between hvCs and low-volume centers (lvCs) by comparing the number of resected lymph nodes (LNs) as the primary endpoint.

RESULTS

A total of 157 patients underwent surgery in 33 centers: 90 patients in four hvCs and 67 patients in 29 lvCs. Laparotomy was more often performed in hvCs (85.6% vs. 59.7%; p < 0.001), as was right hemicolectomy (64.4% vs. 38.8%; p < 0.001), whereas limited ileocolic resection was performed in 18% of patients in lvCs versus none in hvCs. A bi-digital palpation of the entire SI length (95.6% vs. 34.3%, p < 0.001), a cholecystectomy (93.3% vs. 14.9%; p < 0.001), and a mesenteric mass resection (70% vs. 35.8%; p < 0.001) were more often performed in hvCs. The proportion of patients with ≥8 LNs resected was significantly higher (96.3% vs. 65.1%; p < 0.001) in hvCs compared with lvCs, as was the proportion of patients with ≥12 LNs resected (87.8% vs. 52.4%). Furthermore, the number of patients with multiple SI-NETs was higher in the hvC group compared with the lvC group (43.3% vs. 25.4%), as were the number of tumors in those patients (median of 7 vs. 2; p < 0.001).

CONCLUSIONS

Optimal SI-NET resection was significantly more often performed in hvCs. Centralization of surgical care of SI-NETs is recommended.

Laparoscopic and robotic distal pancreatectomy: the choice and the future

INTRODUCTION

Distal pancreatectomy (DP) is currently well established as a minimally invasive surgery (MIS) procedure, using either a laparoscopic (LDP) or robotic (RDP) approach.

METHODS

Out of 83 DP performed between January 2018 and March 2022, 57 cases (68.7%) were performed using MIS: 35 LDP and 22 RDP (da Vinci Xi). We have assessed the experience with the two techniques and analyzed the value of the robotic approach. Cases of conversion have been examined in detail.

RESULTS

The mean operative times for LDP and RDP were 201.2 (SD 47.8) and 247.54 (SD 35.8) minutes, respectively (P = NS). No differences were observed in length of hospital stay or conversion rate: 6 (5-34) vs. 5.6 (5-22) days, and 4 (11.4%) vs. 3 (13.6%) cases, respectively (P = NS). The readmission rate was 3/35 patients (11.4%) treated with LDP and 6/22 (27.3%) cases of RDP (P = NS). There were no differences in morbidity (Dindo-Clavien ≥ III) between the two groups. Mortality was one case in the robotic group (a patient with early conversion due to vascular involvement). The rate of R0 resection was greater and statistically significant in the RDP group (77.1% vs. 90.9%) (P = .04).

CONCLUSION

Minimally invasive distal pancreatectomy (MIDP) is a safe and feasible procedure in selected patients. Surgical planning and stepwise implementation based on prior experience help surgeons successfully perform technically demanding procedures. RDP could be the approach of choice in distal pancreatectomy, and it is not inferior to LDP.

Education of the cancer surgical workforce: Gaps, priorities, and strategies

Cancer is a leading cause of noncommunicable disease-related mortality. The predicted number of new cancer cases will increase from 19.3 million in 2020 to 30.2 million by 2040. To mitigate the cancer burden, it is critical to build capacity of the cancer workforce, especially in systems with limited resources. We provide a global overview of gaps and implementation strategies that can increase the quality and quantity of the global surgical cancer workforce.

Duodenum-Preserving Pancreatic Head Resection for Benign and Premalignant Tumors-a Systematic Review and Meta-analysis of Surgery-Associated Morbidity

BACKGROUND

Pancreatic benign, cystic, and neuroendocrine neoplasms are increasingly detected and recommended for surgical treatment. In multiorgan resection pancreatoduodenectomy or parenchyma-sparing, local extirpation is a challenge for decision-making regarding surgery-related early and late postoperative morbidity.

METHODS

PubMed, Embase, and Cochrane Libraries were searched for studies reporting early surgery-related complications following pancreatoduodenectomy (PD) and duodenum-preserving total (DPPHRt) or partial (DPPHRp) pancreatic head resection for benign tumors. Thirty-four cohort studies comprising data from 1099 patients were analyzed. In total, 654 patients underwent DPPHR and 445 patients PD for benign tumors. This review and meta-analysis does not need ethical approval.

RESULTS

Comparing DPPHRt and PD, the need for blood transfusion (OR 0.20, 95% CI 0.10-0.41, p<0.01), re-intervention for serious surgery-related complications (OR 0.48, 95% CI 0.31-0.73, p<0.001), and re-operation for severe complications (OR 0.50, 95% CI 0.26-0.95, p=0.04) were significantly less frequent following DPPHRt. Pancreatic fistula B+C (19.0 to 15.3%, p=0.99) and biliary fistula (6.3 to 4.3%; p=0.33) were in the same range following PD and DPPHRt. In-hospital mortality after DPPHRt was one of 350 patients (0.28%) and after PD eight of 445 patients (1.79%) (OR 0.32, 95% CI 0.10-1.09, p=0.07). Following DPPHRp, there was no mortality among the 192 patients.

CONCLUSION

DPPHR for benign pancreatic tumors is associated with significantly fewer surgery-related, serious, and severe postoperative complications and lower in-hospital mortality compared to PD. Tailored use of DPPHRt or DPPHRp contributes to a reduction of surgery-related complications. DPPHR has the potential to replace PD for benign tumors and premalignant cystic and neuroendocrine neoplasms of the pancreatic head.

Association of rurality, socioeconomic status, and race with pancreatic cancer surgical treatment and survival

BACKGROUND

Pancreatectomy is a necessary component of curative intent therapy for pancreatic cancer, and patients living in nonmetropolitan areas may face barriers to accessing timely surgical care. We evaluated the intersecting associations of rurality, socioeconomic status (SES), and race on treatment and outcomes of Medicare beneficiaries with pancreatic cancer.

METHODS

We conducted a retrospective cohort study, using fee-for-service Medicare claims of beneficiaries with incident pancreatic cancer (2016-2018). We categorized beneficiary place of residence as metropolitan, micropolitan, or rural. Measures of SES were Medicare-Medicaid dual eligibility and the Area Deprivation Index. Primary study outcomes were receipt of pancreatectomy and 1-year mortality. Exposure-outcome associations were assessed with competing risks and logistic regression.

RESULTS

We identified 45 915 beneficiaries with pancreatic cancer, including 78.4%, 10.9%, and 10.7% residing in metropolitan, micropolitan, and rural areas, respectively. In analyses adjusted for age, sex, comorbidity, and metastasis, residents of micropolitan and rural areas were less likely to undergo pancreatectomy (adjusted subdistribution hazard ratio = 0.88 for rural, 95% confidence interval [CI] = 0.81 to 0.95) and had higher 1-year mortality (adjusted odds ratio = 1.25 for rural, 95% CI = 1.17 to 1.33) compared with metropolitan residents. Adjustment for measures of SES attenuated the association of nonmetropolitan residence with mortality, and there was no statistically significant association of rurality with pancreatectomy after adjustment. Black beneficiaries had lower likelihood of pancreatectomy than White, non-Hispanic beneficiaries (subdistribution hazard ratio = 0.80, 95% CI = 0.72 to 0.89, adjusted for SES). One-year mortality in metropolitan areas was higher for Black beneficiaries (adjusted odds ratio = 1.15, 95% CI = 1.05 to 1.26).

CONCLUSIONS

Rurality, socioeconomic deprivation, and race have complex interrelationships and are associated with disparities in pancreatic cancer treatment and outcomes.

Surgeon supply and healthcare quality: Are revision rates for hip and knee replacements lower in hospitals that employ more surgeons?

We study the link between department-wide surgeon supply and quality of care for two major elective medical procedures. Several countries have adopted policies to concentrate medical procedures in high-volume hospitals. While higher patient volumes might translate to higher quality, we provide evidence for a positive relationship between surgeon supply and hospital revision rates for hip and knee replacement surgery. Hence, hospital performance decreases with higher surgeon supply, and this finding holds conditional on patient volumes.

Teaching modern pancreatic surgery: close relationship between centralization, innovation, and dissemination of care

BACKGROUND

Pancreatic surgery is increasingly moving towards centralization in high-volume centres, supported by evidence on the volume-outcome relationship. At the same time, minimally invasive pancreatic surgery is becoming more and more established worldwide, and interest in new techniques, such as robotic pancreatoduodenectomy, is growing. Such recent innovations are reshaping modern pancreatic surgery, but they also represent new challenges for surgical training in its current form.

METHODS

This narrative review presents a chosen selection of literature, giving a picture of the current state of training in pancreatic surgery, together with the authors' own views, and in the context of centralization and innovation towards minimally invasive techniques.

RESULTS

Centralization of pancreatic surgery at high-volume centres, volume-outcome relationships, innovation through minimally invasive technologies, learning curves in both traditional and minimally invasive surgery, and standardized training paths are the different, but deeply interconnected, topics of this article. Proper training is essential to ensure quality of care, but innovation and centralization may represent challenges to overcome with new training models.

CONCLUSION

Innovations in pancreatic surgery are introduced with the aim of increasing the quality of care. However, their successful implementation is deeply dependent on dissemination and standardization of surgical training, adapted to fit in the changing landscape of modern pancreatic surgery.

Whipple's procedure for pancreatic cancer: training and the hospital environment are more important than volume alone

Background

In our center, patients with pancreatic cancer traditionally had Whipple's resections by general surgery teams until January 2013 when a hepatopancreatobiliary (HPB) was introduced. We compared outcomes before and after introduction of HPB teams.

Methods

Data were collected from the records of all patients booked for Whipple's resections over a 12-year period. The data were divided into two groups: Group A consisted of the 6-year period from January 1, 2007 to December 30, 2012 during which all resections were performed by GS teams. Group B comprised patients in the 6-year period from January 1, 2013 to December 30, 2019 during which operations were performed by HPB teams. All statistical analyses were carried out using SPSS ver 16.0 and a P Value <0.05 was considered statistically significant.

Results

The patients selected for Whipple's resections in Group A had statistically better performance status and lower anaesthetic risk. Despite this, patients in Group A had higher conversions to palliative operations (66% vs 5.3%), longer mean operating time (517±25 vs 367±54 min; P<0.0001), higher blood loss (3687±661 vs 1394±656 ml; P<0.0001), greater transfusion requirements (4.3±1.3 vs 1.9±1.4 units; P<0.001), greater likelihood of prolonged ICU stay (100% vs 40%; P=0.19), higher overall morbidity (75% vs 22.2%; P=0.02), higher major morbidity (75% vs 13.9%; P=0.013), more procedure-related complications (75% vs 9.7%; P=0.003) and higher mortality rates (75% vs 5.6%; P<0.0001). The HPB teams were more likely to perform vein resection and reconstruction to achieve clear margins (26.4% vs 0; P=0.57).

Conclusion

This paper adds to the growing body of evidence that volume alone should not be used as a marker of quality for patients requiring Whipple's procedures.

Survival variability across hospitals after resection for pancreatic adenocarcinoma: A multilevel survival analysis on a high-resolution population-based study

INTRODUCTION

Resection is the cornerstone of curative management for pancreatic ductal adenocarcinoma (PDAC). Hospital surgical volume influence post-operative mortality. Few is known about impact on survival.

METHODS

Population included 763 patients resected for PDAC within the 4 French digestive tumor registries between 2000 and 2014. Spline method was used to determine annual surgical volume thresholds influencing survival. A multilevel survival regression model was used to study center effect.

RESULTS

Population was divided into three groups: low-volume (LVC) (<41 hepatobiliary/pancreatic procedures/year), medium-volume (MVC) (41-233) and high-volume centers (HVC) (>233). Patients in LVC were older (p = 0.02), had a lower rate of disease-free margins (76.7% vs. 77.2% and 69.5%, p = 0.028) and a higher post-operative mortality than in MVC and HVC (12.5% and 7.5% vs. 2.2%; p = 0.004). Median survival was higher in HVC than in other centers (25 vs. 15.2 months, p < 0.0001). Survival variance attributable to center effect accounted for 3.7% of total variance. In multilevel survival analysis, surgical volume explained the inter-hospital survival heterogeneity (non-significant variance after adding the volume to the model p = 0.3). Patients resected in HVC had a better survival than in LVC (HR 0.64 [0.50-0.82], p < 0.0001). There was no difference between MVC and HVC.

CONCLUSION

Regarding center effect, individual characteristics had little impact on survival variability across hospitals. Hospital volume was a major contributor to the center effect. Given the difficulty of centralizing pancreatic surgery, it would be wise to determine which factors would indicate management in a HVC.

The Practice of Pancreatoduodenectomy in India: A Nation-Wide Survey

Introduction The way pancreatoduodenectomy (PD) is performed can vary a lot around the world, and there is no agreed-upon standard approach. To learn more about how PD is practised in India, a survey was conducted among Indian surgeons to gather information about their current practices. Methods A survey was created and shared with surgeons in India who practice pancreatic surgery. It had 33 questions that aimed to capture information about different aspects of PD practice. These questions covered topics such as the surgeons' education and experience, how they evaluated patients before surgery, what they considered during the operation, and how they managed patients after surgery. Results A total of 129 surgeons were sent the survey, and 110 of them completed it. The results showed that 40.9% of the surgeons had less than five years of experience, and 36.4% of them performed more than 15 PDs in a year. When deciding whether to perform preoperative biliary drainage, 60% of surgeons based their decision on the level of bilirubin in the patient's blood, while the rest considered other specific indications. The majority of surgeons (72.7%) looked at the trend of albumin levels to assess the patient's nutritional status before surgery. Venous infiltration was seen as a reason for neoadjuvant therapy by 76.4% of the participants, whereas 95.5% considered upfront surgery in cases of venous abutment. When it came to the type of PD, 40% preferred classical PD, 40.9% preferred pylorus-resecting PD (PRPD), and the rest chose pylorus-preserving PD (PPPD). Pancreatojejunostomy (PJ) was the preferred method for 77.3% of surgeons, while 6.3% preferred pancreatogastrostomy (PG). About 65.5% of surgeons used octreotide selectively during the operation when the duct diameter was small. Nearly all surgeons (94.5%) preferred to secure feeding access during PD, and all of them placed intraperitoneal drains. As for postoperative care, 37.3% of surgeons attempted early oral feeding within 48 hours, while 28.2% preferred to wait at least 48 hours before initiating oral feeds. Conclusions The survey revealed significant differences in how PD is practised among surgeons in India, highlighting the heterogeneity in their approaches and preferences.

Current Perioperative Care in Pancreatoduodenectomy: A Step-by-Step Surgical Roadmap from First Visit to Discharge

Pancreaticoduodenectomy (PD) is a mainstay in the management of periampullary tumors. Treatment algorithms increasingly employ a multimodal strategy, which includes neoadjuvant and adjuvant therapies. However, the successful treatment of a patient is contingent on the execution of a complex operation, whereby minimizing postoperative complications and optimizing a fast and complete recovery are crucial to the overall success. In this setting, risk reduction and benchmarking the quality of care are essential frameworks through which modern perioperative PD care must be delivered. The postoperative course is primarily influenced by pancreatic fistulas, but other patient- and hospital-associated factors, such as frailty and the ability to rescue from complications, also affect the outcomes. A comprehensive understanding of the factors influencing surgical outcomes allows the clinician to risk stratify the patient, thereby facilitating a frank discussion of the morbidity and mortality of PD. Further, such an understanding allows the clinician to practice based on the most up-to-date evidence. This review intends to provide clinicians with a roadmap to the perioperative PD pathway. We review key considerations in the pre-, intra-, and post-operative periods.

Geographical Disparities and Patients' Mobility: A Plea for Regionalization of Pancreatic Surgery in Italy

Patients requiring complex treatments, such as pancreatic surgery, may need to travel long distances and spend extended periods of time away from home, particularly when healthcare provision is geographically dispersed. This raises concerns about equal access to care. Italy is administratively divided into 21 separate territories, which are heterogeneous in terms of healthcare quality, with provision generally decreasing from north to south. This study aimed to evaluate the distribution of adequate facilities for pancreatic surgery, quantify the phenomenon of long-distance mobility for pancreatic resections, and measure its effect on operative mortality. Data refer to patients undergoing pancreatic resections (in the period 2014-2016). The assessment of adequate facilities for pancreatic surgery, based on volume and outcome, confirmed the inhomogeneous distribution throughout Italy. The migration rate from Southern and Central Italy was 40.3% and 14.6%, respectively, with patients mainly directed towards high-volume centers in Northern Italy. Adjusted mortality for non-migrating patients receiving surgery in Southern and Central Italy was significantly higher than that for migrating patients. Adjusted mortality varied greatly among regions, ranging from 3.2% to 16.4%. Overall, this study highlights the urgent need to address the geographical disparities in pancreatic surgery provision in Italy and ensure equal access to care for all patients.

Exploring the Surgical Outcomes of Pancreatic Cancer Resections Performed in Low- Versus High-Volume Centers

Introduction Pancreatic cancer resections comprise a class of complex surgical operations with a high postoperative morbidity rate. Due to the complicated nature of pancreatic resection, individuals who undergo this procedure are advised to visit a high-volume medical center that performs such pancreatic surgeries frequently. However, this specialized treatment option may not be available for uninsured patients or patients with other socioeconomic limitations that may restrict their access to these facilities. To gain a better understanding of the impact of healthcare disparities on surgical outcomes, we aimed to explore if there were significant differences in mortality rate post-pancreatic resection between high- and low-volume hospitals within San Bernardino, Riverside, Los Angeles, and Orange Counties. Methods We utilized the California Health and Human Services Agency (CHHS) California Hospital Inpatient Mortality Rates and Quality Ratings public dataset to compare risk-adjusted mortality rates (RA-MR) of pancreatic cancer resections procedures. We focused on procedures performed in hospitals within San Bernardino, Riverside, Los Angeles, and Orange County from 2012 to 2015. To assess post-resection outcomes in relation to hospital volume, we utilized an independent T-test (significance level was set equal to 0.05) to determine if there is a statistically significant difference in RA-MR after pancreatic resection between high- and low-volume hospitals. Results During the 2012-2015 study period, 57 hospitals across San Bernardino, Riverside, Orange, and Los Angeles Counties were identified to perform a total of 6,204 pancreatic resection procedures. The low-volume hospital group (N=2,539) was associated with a higher RA-MR of M=4.45 (SD=11.86). By comparison, the high-volume hospital group (N=3,665) was associated with a lower RA-MR of M=1.72 (SD=2.61). Conclusion Pancreatic resection surgeries performed at low-volume hospitals resulted in a significantly higher RA-MR compared to procedures done at high-volume hospitals in California.

Defining the Price Tag of Complications Following Pancreatic Surgery: A US National Perspective

INTRODUCTION

Pancreatic surgery tends to have a high rate of postoperative complications due to its complex nature, significantly increasing hospital costs. Our aim was to describe the true association between complications and hospital costs in a national cohort of US patients.

METHODS

The National Inpatient Sample was used to conduct a retrospective analysis of elective pancreatic resections performed between 2004 and 2017, categorizing them based on whether patients experienced major complications (MaC), minor complications (MiC), or no complications (NC). Multivariable quantile regression was used to analyze how costs varied at different percentiles of the cost curve.

RESULTS

Of 37,893 patients, 45.3%, 28.6%, and 26.1% experienced NC, MiC, and MaC, respectively. Factors associated with MaC were a Charlson Comorbidity Index of ≥4, prolonged length of stay, proximal pancreatectomy, older age, male sex, and surgery performed at hospitals with a small number of beds or at urban nonteaching hospitals (all P < 0.01). Multivariable quantile regression revealed significant variation in MiC and MaC across the cost curve. At the 50th percentile, MiC increased the cost by $3352 compared to NC while MaC almost doubled the cost of the surgery, increasing it by $20,215 (both P < 0.01). The association between complications and cost was even greater at the 95th percentile, increasing the cost by $10,162 and $108,793 for MiC and MaC, respectively (P < 0.01).

CONCLUSIONS

MiC and MaC were significantly associated with increased hospital costs. Furthermore, the relationship between MaC and costs was especially apparent at higher percentiles of the cost curve.

Technical options in surgery for artery-involving pancreatic cancer: Invasion depth matters

Background

The artery involvement explains the majority of primary unresectability of non-metastatic pancreatic cancer patients and both arterial resection and artery-sparing dissection techniques are utilized in curative-intent pancreatectomies for artery-involving pancreatic cancer (ai-PC) patients.

Methods

This narrative review summarized the history of resectability evaluation for ai-PC and attempted to interpret its current pitfalls that led to the divergence of resectability prediction and surgical exploration, with a focus on the rationale and the surgical outcomes of the sub-adventitial divestment technique.

Results

The circumferential involvement of artery by tumor currently defined the resectability of ai-PC but insufficient to preclude laparotomy with curative intent. The reasons behind could be: 1. The radiographic involvement of tumor to arterial circumference was not necessarily resulted in histopathological artery wall invasion; 2. the developed surgical techniques facilitated radical resection, better perioperative safety as well as oncological benefit. The feasibility of periadventitial dissection, sub-adventitial divestment and other artery-sparing techniques for ai-PC depended on the tumor invasion depth to the artery, i.e., whether the external elastic lamina (EEL) was invaded demonstrating a hallmark plane for sub-adventitial dissections. These techniques were reported to be complicated with preferable surgical outcomes comparing to arterial resection combined pancreatectomies, while the arterial resection combined pancreatectomies were considered performed in patients with more advanced disease.

Conclusions

Adequate preoperative imaging modalities with which to evaluate the tumor invasion depth to the artery are to be developed. Survival benefits after these techniques remain to be proven, with more and higher-level clinical evidence needed.

Key message

The current resectability evaluation criteria, which were based on radiographic circumferential involvement of the artery by tumor, was insufficient to preclude curative-intent pancreatectomies for artery-involving pancreatic cancer patients. With oncological benefit to be further proven, periarterial dissection and arterial resection have different but overlapping indications, and predicting the tumor invasion depth in major arteries was critical for surgical planning.

The relationship of hospital and surgeon volume indicators and post-operative outcomes in pancreatic surgery: a systematic literature review, meta-analysis and guidance for valid outcome assessment

BACKGROUND

Available evidence on the volume-outcome relationship after pancreatic surgery is limited due to the narrow focus of interventions, volume indicators and outcomes considered as well as due to methodological differences of the included studies. Therefore, we aim to evaluate the volume-outcome relationship following pancreatic surgery following strict study selection and quality criteria, to identify aspects of methodological variation and to define a set of key methodological indicators to consider when aiming for comparable and valid outcome assessment.

METHODS

Four electronic databases were searched to identify studies on the volume-outcome relationship in pancreatic surgery published between the years 2000-2018. Following a double-screening process, data extraction, quality appraisal, and subgroup analysis, results of included studies were stratified and pooled using random effects meta-analysis.

RESULTS

Consistent associations were found between high hospital volume and both postoperative mortality (OR 0.35, 95% CI: 0.29-0.44) and major complications (OR 0.87, 95% CI: 0.80-0.94). A significant decrease in the odds ratio was also found for high surgeon volume and postoperative mortality (OR 0.29, 95%CI: 0.22-0.37).

DISCUSSION

Our meta-analysis confirms a positive effect for both hospital and surgeon volume indicators for pancreatic surgery. Further harmonization (e.g. surgery types, volume cut-offs/definition, case-mix adjustment, reported outcomes) are recommended for future empirical studies.

Volume-outcome relationship in adrenal surgery from 2009-2017 in Germany-a retrospective study

OBJECTIVE

Adrenal resections are rare procedures of a heterogeneous nature. While recent European guidelines advocate a minimum annual caseload for adrenalectomies (6 per surgeon), evidence for a volume-outcome relationship for this surgery remains limited.

DESIGN

A retrospective analysis of all adrenal resections in Germany between 2009 and 2017 using hospital billing data was performed. Hospitals were grouped into three tertiles of approximately equal patient volume.

METHODS

Descriptive, univariate, and multivariate analyses were applied to identify a possible volume-outcome relationship (complications, complication management, and mortality).

RESULTS

Around 17 040 primary adrenal resections were included. Benign adrenal tumors (n = 8,213, 48.2%) and adrenal metastases of extra-adrenal malignancies (n = 3582, 21.0%) were the most common diagnoses. Six hundred and thirty-two low-volume hospitals performed an equal number of resections as 23 high-volume hospitals (median surgeries/hospital/year 3 versus 31, P < .001). Complications were less frequent in high-volume hospitals (23.1% in low-volume hospitals versus 17.3% in high-volume hospitals, P < .001). The most common complication was bleeding in 2027 cases (11.9%) with a mortality of 4.6% (94 patients). Overall in-house mortality was 0.7% (n = 126). Age, malignancy, an accompanying resection, complications, and open surgery were associated with in-house mortality. In univariate analysis, surgery in high-volume hospitals was associated with lower mortality (OR: 0.47, P < .001). In a multivariate model, the tendency remained equal (OR: 0.59, P = .104). Regarding failure to rescue (death in case of complications), there was a trend toward lower mortality in high-volume hospitals.

CONCLUSIONS

The annual caseload of adrenal resections varies considerably among German hospitals. Our findings suggest that surgery in high-volume centers is advantageous for patient outcomes although fatal complications are rare.

Association between the Preoperative C-Reactive Protein-to-Albumin Ratio and the Risk for Postoperative Pancreatic Fistula following Distal Pancreatectomy for Pancreatic Cancer

Postoperative pancreatic fistula (POPF) are major postoperative complications (POCs) following distal pancreatectomy (DP). Notably, POPF may worsen the prognosis of patients with pancreatic cancer. Previously reported risks for POCs include body mass index, pancreatic texture, and albumin levels. Moreover, the C-reactive protein-to-albumin ratio (CAR) is a valuable parameter for prognostication. On the other hand, POCs sometimes lead to a worse prognosis in several cancer types. Thus, we assumed that CAR could be a risk factor for POPFs. This study investigated whether CAR can predict POPF risk in patients with pancreatic cancer following DP. This retrospective study included 72 patients who underwent DP for pancreatic cancer at Ehime University between January 2009 and August 2022. All patients underwent preoperative CAR screening. Risk factors for POPF were analyzed. POPF were observed in 17 of 72 (23.6%) patients. POPF were significantly associated with a higher CAR (p = 0.001). The receiver operating characteristic curve analysis determined the cutoff value for CAR to be 0.05 (sensitivity: 76.5%, specificity: 88.9%, likelihood ratio: 6.88), indicating an increased POPF risk. Univariate and multivariate analysis revealed that CAR ≥ 0.05 was a statistically independent factor for POPF (p < 0.001, p = 0.013). Therefore, CAR has the potential to predict POPF following DP.

Whipple’s pancreaticoduodenectomy at a resource-poor, low-volume center in Trinidad and Tobago

BACKGROUND

Many authorities advocate for Whipple’s procedures to be performed in high-volume centers, but many patients in poor developing nations cannot access these centers. We sought to determine whether clinical outcomes were acceptable when Whipple’s procedures were performed in a low-volume, resource-poor setting in the West Indies.

AIM

To study outcomes of Whipple’s procedures in a pancreatic unit in the West Indies over an eight-year period from June 1, 2013 to June 30, 2021.

METHODS

This was a retrospective study of all patients undergoing Whipple’s procedures in a pancreatic unit in the West Indies over an eight-year period from June 1, 2013 to June 30, 2021.

RESULTS

This center performed an average of 11.25 procedures per annum. There were 72 patients in the final study population at a mean age of 60.2 years, with 52.7% having American Society of Anesthesiologists scores ≥ III and 54.1% with Eastern Cooperative Oncology Group scores ≥ 2. Open Whipple’s procedures were performed in 70 patients and laparoscopic assisted procedures in 2. Portal vein resection/reconstruction was performed in 19 (26.4%) patients. In patients undergoing open procedures there was 367 ± 54.1 min mean operating time, 1394 ± 656.8 mL mean blood loss, 5.24 ± 7.22 d mean intensive care unit stay and 15.1 ± 9.53 d hospitalization. Six (8.3%) patients experienced minor morbidity, 10 (14%) major morbidity and there were 4 (5.5%) deaths.

CONCLUSION

This paper adds to the growing body of evidence that volume alone should not be used as a marker of quality for patients requiring Whipple’s procedures. Low volume centers in resource poor nations can achieve good short-term outcomes. This is largely due to the process of continuous, adaptive learning by the entire hospital.

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.

One hundred most cited article related to pancreaticoduodenectomy surgery: A bibliometric analysis

BACKGROUND

In light of the challenges associated with pancreaticoduodenectomy (PD) and recent key improvements, this bibliometric analysis aimed to analyze the 100 top-cited (T100) articles related to PD surgery to widen the awareness of relevant research on this procedure.

METHODS

The term "pancreaticoduodenectomy" was used to retrieve articles from the Web of Science Core Collection database. The 100 most cited manuscripts in the English language were identified and further analyzed by their countries of origin, publication journals, authors, and themes.

RESULTS

A thorough literature search was performed on the Web of Science until April 2020. The total number of citations for the T100 articles ranged from 227 to 3029. The T100 articles came from 18 different countries, with the USA accounting for the plurality (n = 72). Professor J.L. Cameron from Johns Hopkins Medicine USA published the most articles (n = 22), including one as the first author and two as a co-author. Furthermore, Johns Hopkins Medicine, USA, published the most articles on PD surgery (n = 24), with a total citation count of 14,151. The journal Annals of Surgery published 40 of the T100 articles, with 15,847 citations and an average citation count of 396. Among the T100 articles, the citation frequency following the year of publication showed a parabolic trend, with citations peaking in the 9th year following publication.

CONCLUSION

Our study identified and analyzed the T100 articles in PD surgery. The USA was the dominant country regarding articles, researchers, and institutions. The citations of the articles peaked in the 9th year after publication.

Is There a Doctors' Effect on Patients' Physical Health, Beyond the Intervention and All Known Factors? A Systematic Review

Purpose

Despite billions of doctor visits worldwide each year, little is known on whether doctors themselves affect patients' physical health after accounting for intervention and confounders such as patients' and doctors' data, hospital effects, nor how strong that doctors' effect is. Knowledge of surgeons' and psychotherapists' effects exists, but not for 102 other medical specialties notwithstanding the importance of such knowledge.

Methods

Eligibility Criteria: Randomized controlled trials (RCTs), case-control, and cohort studies including medical doctors except surgeons for any intervention, reporting the proportion of variance in patients' outcomes owing to the doctors (random effects), or the fixed effects of grading doctors by outcomes, after multivariate adjustment. Exclusions: studies of <15 doctors or solely reporting doctors' effects for known variables.

Sources

Medline, Embase, PsycINFO, inception to June 2020. Manual search for papers referring/referred to by resulting studies.

Risk of Bias

Using Newcastle-Ottawa scale.

Results

Despite all medical interventions bar surgery being eligible, only thirty cohort papers were found, covering 36,239 doctors, with 10 specialties, 21 interventions, 60 outcomes (17 unique). Studies reported doctors' effects by grading doctors from best to worst, or by diversely calculating the doctor-attributed percentage of patients' outcome variation, ie the intra-class correlation coefficient (ICC). Sixteen studies presented fixed effects, 18 random effects, and 3 another approach. No RCTs found. Thirteen studies reported exceptionally good and/or poor performers with confidence intervals wholly outside the average performance. ICC range 0 to 33%, mean 3.9%. Highly diverse reporting, meta-analysis therefore not applicable.

Conclusion

Doctors, on their own, can affect patients' physical health for many interventions and outcomes. Effects range from negligible to substantial, even after accounting for all known variables. Many published cohorts may reveal valuable information by reanalyzing their data for doctors' effects. Positive and negative doctor outliers appear regularly. Therefore, it can matter which doctor is chosen.

The Doctors' Effect on Patients' Physical Health Outcomes Beyond the Intervention: A Methodological Review

Background

Previous research suggests that when a treatment is delivered, patients' outcomes may vary systematically by medical practitioner.

Objective

To conduct a methodological review of studies reporting on the effect of doctors on patients' physical health outcomes and to provide recommendations on how this effect could be measured and reported in a consistent and appropriate way.

Methods

The data source was 79 included studies and randomized controlled trials from a systematic review of doctors' effects on patients' physical health. We qualitatively assessed the studies and summarized how the doctors' effect was measured and reported.

Results

The doctors' effects on patients' physical health outcomes were reported as fixed effects, identifying high and low outliers, or random effects, which estimate the variation in patient health outcomes due to the doctor after accounting for all available variables via the intra-class correlation coefficient. Multivariable multilevel regression is commonly used to adjust for patient risk, doctor experience and other demographics, and also to account for the clustering effect of hospitals in estimating both fixed and random effects.

Conclusion

This methodological review identified inconsistencies in how the doctor's effect on patients' physical health outcomes is measured and reported. For grading doctors from worst to best performances and estimating random effects, specific recommendations are given along with the specific data points to report.

Intensive Care Unit Volume of Sepsis Patients Does Not Affect Mortality: Results of a Nationwide Retrospective Analysis

BACKGROUND

There is little research evaluating outcomes from sepsis in intensive care units (ICUs) with lower sepsis patient volumes as compared to ICUs with higher sepsis patient volumes. Our objective was to compare the outcomes of septic patients admitted to ICUs with different sepsis patient volumes.

MATERIALS AND METHODS

We included all patients from the eICU-CRD database admitted for the management of sepsis with blood lactate ≥ 2mmol/L within 24 hours of admission. Our primary outcome was ICU mortality. Secondary outcomes included hospital mortality, 30-day ventilator free days, and initiation of renal replacement therapy (RRT). ICUs were grouped in quartiles based on the number of septic patients treated at each unit.

RESULTS

10,716 patients were included in our analysis; 272 (2.5%) in low sepsis volume ICUs, 1,078 (10.1%) in medium-low sepsis volume ICUs, 2,608 (24.3%) in medium-high sepsis volume ICUs, and 6,758 (63.1%) in high sepsis volume ICUs. On multivariable analyses, no significant differences were documented regarding ICU and hospital mortality, and ventilator days in patients treated in lower versus higher sepsis volume ICUs. Patients treated at lower sepsis volume ICUs had lower rates of RRT initiation as compared to high volume units (medium-high vs. high: OR = 0.78, 95%CI = 0.66-0.91, P-value = 0.002 and medium-low vs. high: OR = 0.57, 95%CI = 0.44-0.73, P-value < 0.001).

CONCLUSION

The previously described volume-outcome association in septic patients was not identified in an intensive care setting.

Is There a Surgeons’ Effect on Patients’ Physical Health, Beyond the Intervention, That Requires Further Investigation? A Systematic Review

Objective

To find and review published papers researching surgeons’ effects on patients’ physical health. Clinical outcomes of surgery patients with similar prognoses cannot be fully explained by surgeon skill or experience. Just as there are “hospital” and “psychotherapist” effects, there may be “surgeons” effects that persist after controlling for known variables like patient health and operation riskiness.

Methods

Cohort studies and randomized controlled trials (RCTs) of any surgical intervention, which, after multivariate adjustment, either showed proportion of variance in patients’ physical health outcomes due to surgeons (random effects) or graded surgeons from best to worst (fixed effects). Studies with <15 surgeons or only ascribing surgeons’ effects to known variables excluded. Medline, PubMed, Embase, and PsycINFO were used for search until June 2020. Manual search for papers referring/referred by resulting studies. Risk of bias assessed by Cochrane risk-of-bias tool and Newcastle–Ottawa Scale.

Results

Included studies: 52 cohort studies and three RCTs of 52,436+ surgeons covering 102 outcomes (33 unique). Studies either graded surgeons from best to worst or calculated the intra-class correlation coefficient (ICC), the percentage of patients’ variation due to surgeons, in diverse ways. Sixteen studies showed exceptionally good and/or bad performers with confidence intervals wholly above or below the average performance. ICCs ranged from 0 to 47%, median 4.0%. There are no well-established reporting standards; highly heterogeneous reporting, therefore no meta-analysis.

Discussion

Interpretation: There is a surgeons' effect on patients’ physical health for many types of surgeries and outcomes, ranging from small to substantial. Surgeons with exceptional patient outcomes appear regularly even after accounting for all known confounding variables. Many existing cohort studies and RCTs could be reanalyzed for surgeons’ effects especially after methodological reporting guidelines are published.

Conclusion

In terms of patient outcomes, it can matter which surgeon is chosen. Surgeons with exceptional patient outcomes are worth studying further.

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Incidence of Liver Resection Following the Introduction of Caseload Requirements for Liver Surgery in Switzerland

Background

Centralization of care is an established concept in complex visceral surgery. Switzerland introduced case load requirements (CR) in 2013 in five areas of cancer surgery. The current study investigates the effects of CR on indication and mortality in liver surgery.

Methods

This is a retrospective analysis of a complete national in-hospital data set including all admissions between January 1, 2005, and December 31, 2015. Primary outcome variables were the incidence proportion and the 60-day in-hospital mortality of liver resections. Incidence proportion was calculated as the overall yearly number of liver resections performed in relation to the population living in Switzerland before and after the introduction of CR.

Results

Our analysis shows an increase number of liver resections compared to the period before introduction of CR from 2005–2012 (4.67 resections/100,000) to 2013–2015 (5.32 resections/100,000) after CR introduction. Age-adjusted incidence proportion increased by 14% (OR 1.14 95 CI [1.07–1.22]). National in-hospital mortality remained stable before and after CR (4.1 vs 3.7%), but increased in high-volume institutions (3.6 vs 5.6%). The number of hospitals performing liver resections decreased after the introduction of CR from 86 to 43. Half of the resections were performed in institutions reaching the stipulated numbers (53% before vs 49% after introduction of CR). After implementation of CR, patients undergoing liver surgery had more comorbidities (88 vs 92%).

Conclusion

The introduction of CR for liver surgery in Switzerland in 2013 was accompanied by an increase in operative volume with limited effects on centralization of care.

Learning Curves in Open, Laparoscopic, and Robotic Pancreatic Surgery: A Systematic Review and Proposal of a Standardization

Objective

To depict and analyze learning curves for open, laparoscopic, and robotic pancreatoduodenectomy (PD) and distal pancreatectomy (DP).

Background

Formal training is recommended for safe introduction of pancreatic surgery but definitions of learning curves vary and have not been standardized.

Methods

A systematic search on PubMed, Web of Science, and CENTRAL databases identified studies on learning curves in pancreatic surgery. Primary outcome was the number needed to reach the learning curve as defined by the included studies. Secondary outcomes included endpoints defining learning curves, methods of analysis (statistical/arbitrary), and classification of learning phases.

Results

Out of 1115 articles, 66 studies with 14,206 patients were included. Thirty-five studies (53%) based the learning curve analysis on statistical calculations. Most often used parameters to define learning curves were operative time (n = 51), blood loss (n = 17), and complications (n = 10). The number of procedures to surpass a first phase of learning curve was 30 (20-50) for open PD, 39 (11-60) for laparoscopic PD, 25 (8-100) for robotic PD (P = 0.521), 16 (3-17) for laparoscopic DP, and 15 (5-37) for robotic DP (P = 0.914). In a three-phase model, intraoperative parameters improved earlier (first to second phase: operating time -15%, blood loss -29%) whereas postoperative parameters improved later (second to third phase: complications -46%, postoperative pancreatic fistula -48%). Studies with higher sample sizes showed higher numbers of procedures needed to overcome the learning curve (rho = 0.64, P < 0.001).

Conclusions

This study summarizes learning curves for open-, laparoscopic-, and robotic pancreatic surgery with different definitions, analysis methods, and confounding factors. A standardized reporting of learning curves and definition of phases (competency, proficiency, mastery) is desirable and proposed.

The Impact of Hospital Level of Care on the Management of Acute Cholecystitis: a Population-Based Study

BACKGROUND

The organization of healthcare could have an impact on the outcome of patients treated for acute cholecystitis (AC). The aim of this study was to analyze the way in which patients with AC are managed relative to the level of care by the treating hospital.

METHODS

Data were collected from the Swedish Register for Gallstone Surgery and ERCP (GallRiks). Cholecystectomies between 2010 and 2019 were included. The inclusion criterion was acute cholecystectomy in patients with AC operated at either tertiary referral centers (TRCs) or regional hospitals.

RESULTS

A total of 24,194 cholecystectomies with AC met the inclusion criterion. The time between admission and acute surgery was significantly elongated at TRCs compared with regional hospitals (2.2 ± 1.7 days vs. 1.6 ± 1.4 days, mean ± SD; p < 0.0001). Patients with a history of AC were more frequent at TRC (10.1% vs. 8.9%, p < 0.0056) and had a higher adverse event rate compared with those at regional hospitals (OR 1.61; CI 1.40-1.84, p < 0.0001). Surprisingly, an increased number of hospital beds correlated slightly with an increased number of days between admission and surgery (R² = 0.132; p = 0.0075).

CONCLUSION

Compared with regional hospitals, patients with AC had to wait longer at TRCs before surgery. A history of AC significantly increased the risk of adverse events. These findings indicate that logistic and organizational aspects of hospital care may affect the management of patients with AC. However, whether these findings can be generalized to healthcare organizations outside Sweden requires further investigation.

Impact of pylorus preservation on delayed gastric emptying after pancreaticoduodenectomy-analysis of 5,000 patients based on the German StuDoQ|Pancreas-Registry

BACKGROUND

Delayed gastric emptying (DGE) is one of the most common complications after pancreatic head resection. It leads to increased length of hospital stay, high costs for healthcare systems and reduced quality of life. The primary aim of the study was to assess the impact of pylorus preservation, respectively resection on the occurrence of DGE in patients undergoing pancreaticoduodenectomy (PD).

METHODS

All cases of pylorus-resecting PD (PRPD) and pylorus-preserving PD (PPPD) entered in the StuDoQ|Pancreas nationwide registry of the German Society of General and Visceral Surgery from 01/01/2014 until 31/12/2018 including demographics, surgical techniques, histopathological and perioperative data were retrospectively analyzed. This study was approved by the ethics committee of the Ruhr-University Bochum, Germany.

RESULTS

Data of 5,080 patients were enrolled. PPPD was the method of choice (70.4%). Pylorus preservation had no impact on the occurrence of DGE (20.3% vs. 21.5%, P=0.33), but further risk factors could be identified. The comparison of PPPD and PRPD groups showed statistically significant differences in the surgical approach (primary open approach, 94.8% vs. 98.0%, P<0.001), duration of surgery (326.4 vs. 352.1 minutes, P<0.001), technique of pancreatic anastomosis (pancreaticojejunostomy vs. pancreaticojejunostomy), 78.6% vs. 85.2%, P<0.001).

CONCLUSIONS

Patient factors, intraoperative factors, duration of surgery and postoperative factors (postoperative pancreatic fistula, biliary leakage and other surgical complications) were identified as risk factors for DGE. Future research should focus on register-based, prospective, randomised-controlled studies such as the currently recruiting "PyloResPres trial".

The Effect of Increase in Clinical Experience on Morbidity and Mortality After Pancreaticoduodenectomy Surgery

<b> Introduction:</b> Pancreaticoduodenectomy surgery is widely accepted and applied worldwide for periampullary tumors. Despite the decline in mortality rates from 40% to 3% with the advances in surgical technique, morbidity is still high (40–50%). </br></br> <b>Aim:</b> We aimed to investigate the effect of increased clinical experience on the length of hospital stay, morbidity, mortality, and survival after pancreaticoduodenectomy. </br></br> <b> Materials and methods:</b> The files of patients who underwent pancreaticoduodenectomy in our hospital between January 2007 and January 2018 were retrospectively reviewed and divided into four groups by years. Demographics, body mass index (BMI, kg/m2), medical history, preoperative biliary drainage application, surgical technique, histopathological features, postoperative morbidity, mortality, and survival were investigated. </br></br> <b> Results: </b> There was no difference between the groups in terms of age, gender, comorbid disease, history of biliary drainage, surgical technique, and operation time (P > 0.05). The rate of postoperative complications has decreased over the years (P = 0.01). According to the Clavien-Dindo scale, the complication severity decreased significantly over the years (P = 0.05). The overall survival of the patients increased by years (P = 0.03); the Early postoperative mortality rate decreased in the first month (<30 days) (P = 0.04). </br></br> <b> Conclusion:</b> With increased clinical experience, morbidity and mortality decrease, overall survival is prolonged after pancreaticoduodenectomy procedure.

Mortality, complications and failure to rescue after surgery for esophageal, gastric, pancreatic and liver cancer patients based on minimum caseloads set by the German Cancer Society

BACKGROUND

The German Cancer Society (DKG) board certifies hospitals in treating esophageal, gastric, liver and pancreatic cancer among others. There has been no systematic verification of the number of major surgical resections set by DKG certification with regards to in-house mortality and failure to rescue (FtR).

METHODS

This is a retrospective analysis of anonymized nationwide hospital billing data (DRG data, 2009-2017). Inclusion criteria were based on the annual surgical minimum caseload (SMC) in accordance with DKG certification.

RESULTS

171,429 datasets were identified, including 31,140 esophageal, 54,155 gastric, 57,343 pancreatic and 28,791 liver resections. In-house mortality ranged from 6.2% for gastric resections to 8.1% for pancreatic resections. Differences in in-house mortality between hospitals which fulfilled SMC on average and those which did not fulfill SMC on average were 40.8% (5.3% vs 8.2%) for esophageal, 32.3% (4.8% vs 6.8%) for gastric and 45.7% (6.1% vs 9.8%) for pancreatic resections, while it was 8.2% higher in SMC-hospitals (7.6% vs 7.0%) for liver resections. Complication occurrence rates for esophageal, gastric and pancreatic resections were similar in SMC- and non-SMC-hospitals while FtR in hospitals fulfilling SMC was significantly lower. Data for liver resections demonstrated the same trends only in a sub-analysis of complex procedures.

CONCLUSION

This study demonstrates an association between caseload threshold defined by DKG and lower mortality in esophageal, gastric, pancreatic and complex liver surgery. In these resections, FtR was reduced if SMC was fulfilled.

Curing pancreatic cancer

The distinct biology of pancreatic cancer with aggressive and early invasive tumor cells, a tumor promoting microenvironment, late diagnosis, and high therapy resistance poses major challenges on clinicians, researchers, and patients. In current clinical practice, a curative approach for pancreatic cancer can only be offered to a minority of patients and even for those patients, the long-term outcome is grim. This bitter combination will eventually let pancreatic cancer rise to the second leading cause of cancer-related mortalities. With surgery being the only curative option, complete tumor resection still remains the center of pancreatic cancer treatment. In recent years, new developments in neoadjuvant and adjuvant treatment have emerged. Together with improved perioperative care including complication management, an increasing number of patients have become eligible for tumor resection. Basic research aims to further increase these numbers by new methods of early detection, better tumor modelling and personalized treatment options. This review aims to summarize the current knowledge on clinical and biologic features, surgical and non-surgical treatment options, and the improved collaboration of clinicians and basic researchers in pancreatic cancer that will hopefully result in more successful ways of curing pancreatic cancer.

An aberrant right hepatic artery arising from the gastroduodenal artery: a pitfall encountered during pancreaticoduodenectomy

PURPOSE

Among the variations of the right hepatic artery (RHA), the identification of an aberrant RHA arising from the gastroduodenal artery (GDA) is vital for avoiding damage to the RHA during surgery, since ligation of the GDA is necessary during pancreaticoduodenectomy (PD). However, this variation is not frequently reported. The purpose of this study was to focus on an aberrant RHA arising from the GDA, which was not noted in the classifications reported by Michels and Hiatt.

METHODS

A total of 574 patients undergoing a PD between Jan 2001 and Dec 2015 at a tertiary care hospital in Switzerland (n = 366) and between Jan 2009 and May 2015 at a hospital in Japan (n = 208) were included in the analysis. Of these, preoperative CT angiography or/and MRI angiography findings were available for 532 patients. We retrospectively analyzed the hepatic artery variations, patient demographics, and surgical outcomes.

RESULTS

Among the 532 patients who received a PD, an RHA originating from the GDA was observed in 19 cases (3.5%). Eleven patients (2.1%) had both an aberrant RHA and an aberrant left hepatic artery (LHA) (Hiatt Type 4). Six patients (1.2%) had a replaced CHA arising from the SMA (Hiatt Type 5). We could, therefore, correctly identify the aberration in all cases.

CONCLUSIONS

We observed rarely reported but important aberrant RHA variations arising from the GDA. To prevent injury during PD in patients with this type of aberrant RHA, intensive preparations using CT and/or MRI imaging before surgery and intraoperative liver Doppler ultrasonography are considered to be essential.

Does the Volume-Outcome Association in Pancreas Cancer Surgery Justify Regionalization of Care? A Review of Current Controversies

INTRODUCTION

Increasing hospital or surgeon volume is associated with improved outcomes among patients with pancreatic cancer. Promotion of regionalized care is based on this volume-outcome association. However, other research has exposed nuances and complexities inherent to this association that should be considered when promoting regionalized care models. We herein provide a critical review of the literature on the volume-outcome association and a discussion of areas of ongoing controversy.

METHODS

A PubMed literature search was conducted for the years 1995-2020. Peer reviewed original research studies were selected for critical review based on study design, potential to draw meaningful conclusions from the data, and discussion of current knowledge gaps.

RESULTS

Based on the cumulative published literature, hospital/surgeon volume and patient mortality are inversely related. However, it remains unclear whether volume is a proxy for other more causative variables inherent in high-volume centers. Interpretation of the volume-outcome association is made more difficult to interpret due to the large variation in the definition of high volume, difficulty in isolating the individual impact of surgeon versus hospital volume, challenges in quantifying health system processes related to volume, and the fact that some low-volume centers consistently achieve excellent clinical results. Implementation of true regionalized care models has been rare, likely reflecting both health system and patient level challenges.

CONCLUSION

The volume-outcome association has been consistently demonstrated to be important to the care of patients with pancreas cancer. The underlying mechanism of this association to explain the overall benefit is likely multifactorial. Better understanding of what drives the volume-outcome association may increase access to optimized care for a broader range of hospital systems and patients.

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.

Pancreatic Cancer Surgery Following Emergency Department Admission: Understanding Poor Outcomes and Disparities in Care

BACKGROUND

The impact of emergency department admission prior to pancreatic resection on perioperative outcomes is not well described. We compared patients who underwent pancreatic cancer surgery following admission through the emergency department (ED-surgery) with patients receiving elective pancreatic cancer surgery (elective) and outcomes.

STUDY DESIGN

The Nationwide Inpatient Sample database was used to identify patients undergoing pancreatectomy for cancer over 5 years (2008-2012). Demographics and hospital characteristics were assessed, along with perioperative outcomes and disposition status.

RESULTS

A total of 8158 patients were identified, of which 516 (6.3%) underwent surgery after admission through the ED. ED-surgery patients were more often socioeconomically disadvantaged (non-White 39% vs. 18%, Medicaid or uninsured 24% vs. 7%, from lowest income area 33% vs. 21%; all p < .0001), had higher comorbidity (Elixhauser score > 6: 44% vs. 26%, p < .0001), and often had pancreatectomy performed at sites with lower annual case volume (< 7 resections/year: 53% vs. 24%, p < .0001). ED-surgery patients were less likely to be discharged home after surgery (70% vs. 82%, p < .0001) and had higher mortality (7.4% vs. 3.5%, p < .0001). On multivariate analysis, ED-surgery was independently associated with a lower likelihood of being discharged home (aOR 0.55 (95%CI 0.43-0.70)).

CONCLUSION

Patients undergoing pancreatectomy following ED admission experience worse outcomes compared with those who undergo surgery after elective admission. The excess of socioeconomically disadvantaged patients in this group suggests factors other than clinical considerations alone drive this decision. This study demonstrates the need to consider presenting patient circumstances and preoperative oncologic coordination to reduce disparities and improve outcomes for pancreatic cancer surgery.

Influence of the introduction of caseload requirements on indication for visceral cancer surgery in Switzerland

BACKGROUND

In 2013 Swiss health authorities implemented annual hospital caseload requirements (CR) for five areas of visceral surgery. We assess the impact of the implementation of CR on indication for surgery in esophageal, pancreatic and rectal cancer.

MATERIALS AND METHODS

Retrospective analysis of national registry data of all inpatient admissions between January 1st^, 2005 and December 31st^, 2015. Primary end-point was the age-adjusted resection rate for esophageal, pancreatic and rectal cancer among patients with at least one cancer-specific hospitalization per year. We calculated age-adjusted rate ratios for period effects before and after implementation of CR and odds ratios (OR) based on a generalized estimation equation. A relative increase of 5% in age-adjusted relative risk was set a priori as relevant from a health policy perspective.

RESULTS

Age-adjusted resection rates before and after the implementation of CR were 0.12 and 0.13 (Relative Risk [RR] 1.08; 95%-Confidence Interval [CI] 0.85-1.36) in esophageal cancer, 0.22 and 0.26 (RR 1.17; 95%-CI 0.85-1.58) in pancreatic cancer and 0.38 and 0.43 (RR 1.14; 95%-CI 0.99-1.30) in rectal cancer. In adjusted models OR for resection after the implementation of CR were 1.40 (95%-CI 1.24-1.58) in esophageal cancer, 1.05 (95%-CI 0.96-1.15) in pancreatic cancer and 0.92 (95%-CI 0.87-0.97) in rectal cancer.

CONCLUSION

Implementation of CR was associated with an increase of resection rates above the a priori set margins in all resections groups. In adjusted models, odds for resection were significantly higher for esophageal cancer, while they remained unchanged for pancreatic and decreased for rectal cancer.