Effect of Hospital Volume on Surgical Outcomes After Pancreaticoduodenectomy: A Systematic Review and Meta-analysis. Ann Surg. 2016;263:664-672. [PMID: 26636243 DOI: 10.1097/sla.0000000000001437]

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.

Potential Health Disparities in the Early Detection and Prevention of Pancreatic Cancer

INTRODUCTION

Pancreatic cancer remains one of the deadliest cancers in the United States. Some types of pancreatic cysts, which are being detected more frequently and often incidentally on imaging, have the potential to develop into pancreatic cancer and thus provide a valuable window of opportunity for cancer interception. Although racial disparity in pancreatic cancer has been described, little is known regarding health disparities in pancreatic cancer prevention. In the present study, we investigate potential health disparities along the continuum of care for pancreatic cancer.

METHODS

The racial and ethnic composition of pancreatic patients at high-volume centers in Indiana were evaluated, representing patients undergoing surgery for pancreatic cancer (n=390), participating in biobanking (972 pancreatic cancer patients and 1984 patients with pancreatic disease), or being monitored for pancreatic cysts at an early detection center (n=1514). To assess racial disparities and potential differences in decision-making related to pancreatic cancer prevention and early detection, an exploratory online survey was administered through a volunteer registry (n=708).  Results: We show that despite comprising close to 10% or 30% of the Indiana or Indianapolis population, respectively, African Americans make up only about 4-5% of our study cohorts consisting of patients undergoing pancreatic surgery or participating in biobanking and early detection. Analysis of online survey results revealed that given the hypothetical situation of being diagnosed with a pancreatic cyst or pancreatic cancer, the vast majority of respondents (>90%) would agree to undergo surveillance or surgery, respectively, regardless of race. Only a minority (3-12%) acknowledged any significant transportation, financial, or emotional barriers that would impact a decision to undergo surveillance or surgery. This suggests that the observed racial disparities may be due in part to the existence of other barriers that lie upstream of this decision point.

CONCLUSION

Racial disparities exist not only for pancreatic cancer but also at earlier points along the continuum of care such as prevention and early detection. To our knowledge, this is the first study to document racial disparity in the management of patients with pancreatic cysts who are at risk of developing pancreatic cancer. Our results suggest that improving access to information and care for such at-risk individuals may lead to more equitable outcomes.

Comparing oncologic and surgical outcomes of robotic and laparoscopic pancreatoduodenectomy in patients with pancreatic cancer: a propensity-matched analysis

INTRODUCTION

Minimally invasive Pancreatoduodenectomy (MIPD), or the Whipple procedure, is increasingly utilized. No study has compared laparoscopic (LPD) and robotic (RPD) approaches, and the impact of the learning curve on oncologic, technical, and post-operative outcomes remains relatively understudied.

METHODS

The National Cancer Database was queried for patients undergoing LPD or RPD from 2010 to 2020 with a diagnosis of pancreatic cancer. Outcomes were compared between approaches using propensity-score matching (PSM); the impact of annual center-level volume of MIPD was also assessed by dividing volume into quartiles.

RESULTS

A total of 3,342 patients were included. Most (n = 2,716, 81.3%) underwent LPD versus RPD (n = 626, 18.7%). There was a high rate (20.2%, n = 719) of positive margins. Mean length-of-stay (LOS) was 10.4 ± 8.9 days. Thirty-day mortality was 2.8% (n = 92) and ninety-day mortality was 5.7% (n = 189). PSM matched 625 pairs of patients receiving LPD or RPD. After PSM, there was no differences between groups based on age, sex, race, CCI, T-stage, neoadjuvant chemo/radiotherapy, or type of PD. After PSM, there was a higher rate of conversion to open (HR = 0.68, 95%CI = 0.50-0.92)., but there was no difference in LOS (HR = 1.00, 95%CI = 0.92-1.11), 30-day readmission (HR = 1.08, 95% CI = 0.68-1.71), 30-day (HR = 0.78, 95% CI = 0.39-1.56) or 90-day mortality (HR = 0.70, 95% CI = 0.42-1.16), ability to receive adjuvant therapy (HR = 1.15, 95% CI = 0.92-1.44), nodal harvest (HR = 1.01, 95%CI = 0.94-1.09) or positive margins (HR = 1.19, 95% CI = 0.89-1.59). Centers in lower quartiles of annual volume of MIPD demonstrated reduced nodal harvest (p = 0.005) and a higher rate of conversion to open (p = 0.038). Higher-volume centers had a shorter LOS (p = 0.012), higher rate of initiation of adjuvant therapy (p = 0.042), and, most strikingly, a reduction in 90-day mortality (p = 0.033).

CONCLUSION

LPD and RPD have similar surgical and oncologic outcomes, with a lower rate of conversion to open in the robotic cohort. The robotic technique does not appear to eliminate the "learning curve", with higher volume centers demonstrating improved outcomes, especially seen at minimum annual volume of 5 cases.

Cavitron ultrasonic surgical aspirator (CUSA) compared with conventional pancreatic transection in distal pancreatectomy: study protocol for the randomised controlled CUSA-1 pilot trial

BACKGROUND

Postoperative pancreatic fistula (POPF) remains the most common and serious complication after distal pancreatectomy. Many attempts at lowering fistula rates have led to unrewarding insignificant results as still up to 30% of the patients suffer from clinically relevant POPF. Therefore, the development of new innovative methods and procedures is still a cornerstone of current surgical research.The cavitron ultrasonic surgical aspirator (CUSA) device is a well-known ultrasound-based parenchyma transection method, often used in liver and neurosurgery which has not yet been thoroughly investigated in pancreatic surgery, but the first results seem very promising.

METHODS

The CUSA-1 trial is a randomised controlled pilot trial with two parallel study groups. This single-centre trial is assessor and patient blinded. A total of 60 patients with an indication for open distal pancreatectomy will be intraoperatively randomised after informed consent. The patients will be randomly assigned to either the control group with conventional pancreas transection (scalpel or stapler) or the experimental group, with transection using the CUSA device. The primary safety endpoint of this trial will be postoperative complications ≥grade 3 according to the Clavien-Dindo classification. The primary endpoint to investigate the effect will be the rate of POPF within 30 days postoperatively according to the ISGPS definition. Further perioperative outcomes, including postpancreatectomy haemorrhage, length of hospital stay and mortality will be analysed as secondary endpoints.

DISCUSSION

Based on the available literature, CUSA may have a beneficial effect on POPF occurrence after distal pancreatectomy. The rationale of the CUSA-1 pilot trial is to investigate the safety and feasibility of the CUSA device in elective open distal pancreatectomy compared with conventional dissection methods and gather the first data on the effect on POPF occurrence. This data will lay the groundwork for a future confirmatory multicentre randomised controlled trial.

ETHICS AND DISSEMINATION

The CUSA-1 trial protocol was approved by the ethics committee of the University of Heidelberg (No. S-098/2022). Results will be published in an international peer-reviewed journal and summaries will be provided in lay language to study participants and their relatives.

TRIAL REGISTRATION NUMBER

DRKS00027474.

Impact of institutional volume on short- and long-term outcomes after laparoscopic colectomy

INTRODUCTION

The impact of institutional volume on postoperative outcomes after laparoscopic colectomy is still being debated. This study aimed to investigate whether differences in postoperative outcomes of laparoscopic colon resection exist between high- and low-volume centers.

METHODS

Data were reviewed for 1360 patients who underwent laparoscopic colectomy for colon cancer between 2016 and 2022. Patients were divided according to whether they were treated at a high-volume center (≥100 colorectal surgeries annually; n = 947) or a low-volume center (<100 colorectal surgeries annually; n = 413). Propensity score matching was applied to balance covariates and minimize selection biases that could affect outcomes. Finally, 406 patients from each group were matched.

RESULTS

After matching, patients from high-volume centers showed a higher number of retrieved lymph nodes (19 vs. 17, p < .001) and more frequent involvement of expert surgeons (98.3% vs. 88.4%, p < .001). Postoperative complication rates were similar between groups (p = .488). No significant differences between high- and low-volume centers were seen in relapse-free survival (88.8% each, p = .716) or overall survival (85.7% vs. 82.8%, p = .480).

CONCLUSION

The present study suggests that in appropriately educated organizations, relatively safe procedures and good prognosis may be obtained for laparoscopic colectomy cases, regardless of institutional volume.

Proposal of a Network System to Solve the Problem of Small Volume in Liver Transplantation; Catholic Medical Center Network

INTRODUCTION

Liver transplantation (LT) is a complex and demanding procedure associated with significant perioperative challenges and risks. Concerns have arisen regarding LT outcomes in low-volume centers. We implemented an integrated training and surgical team network to address these concerns within the Catholic Medical Center (CMC) network. This study presents a comprehensive review of our 9-year LT experience within the CMC medical network.

METHOD

A retrospective study of LT procedures conducted between January 2013 and August 2021 in 6 CMC-affiliated hospitals was performed. One center was categorized as a high-volume center, conducting over 60 cases annually, and the remaining 5 were considered small-volume centers. The primary endpoints assessed were 1-year and 5-year survival rates.

RESULTS

A total of 793 LTs were performed during the study period. The high-volume center performed 411 living donor LT (LDLT) cases and 127 deceased donor LT (DDLT) cases. Also, 146 LDLT cases and 109 DDLT cases were performed in 5 small-volume centers. One-year and 5-year patient survival for LDLT recipients was 88.3% and 78.8% in the high-volume center and 85.6% and 80.6% in the low-volume center. Five-year survival was not significantly different in small-volume centers (P = .903). For DDLT recipients, 1-year and 5-year patient survival was 80.3% and 70.6% in the high-volume center and 76.1% and 67.6% in the low-volume center. In DDLT cases, 5-year survival was not significantly different in small-volume centers (P = .445).

CONCLUSION

In conclusion, comparable outcomes for liver transplantation can be obtained in a small-volume center with a high level of integrated training systems and networks.

Impact of Medicaid Expansion on Surgical Care and Outcomes for Hepatobiliary Malignancies

BACKGROUND

As part of the Patient Protection and Affordable Care Act, some states expanded Medicaid eligibility to adults with incomes below 138% of the federal poverty line. While this resulted in an increased proportion of insured residents, its impact on the diagnosis and treatment of hepatopancreaticobiliary (HPB) cancers has not been studied.

STUDY DESIGN

The National Cancer Database (NCDB) from 2010 to 2017 was used. Patients diagnosed with HPB malignancies in states which expanded in 2014 were compared to patients in non-expansion states. Subset analyses of patients who underwent surgery and those in high-risk socioeconomic groups were performed. Outcomes studied included initiation of treatment within 30 days of diagnosis, stage at diagnosis, care at high volume or academic center, perioperative outcomes, and overall survival. Adjusted difference-in-differences analysis was performed.

RESULTS

A total of 345,684 patients were included, of whom 55% resided in non-expansion states and 54% were diagnosed with pancreatic cancer. Overall survival was higher in states with Medicaid expansion (HR .90, 95% CI [.88-.92], P < .01). There were also better postoperative outcomes including 30-day mortality (.67 [.57-.80], P < .01) and 30-day readmissions (.87 [.78-.97], P = .02) as well as increased likelihood of having surgery in a high-volume center (1.42 [1.32-1.53], P < .01). However, there were lower odds of initiating care within 30 days of diagnosis (.77 [.75-.80], P < .01) and higher likelihood of diagnosis with stage IV disease (1.09 [1.06-1.12], P < .01) in expansion states.

CONCLUSION

While operative outcomes and overall survival from HPB cancers were better in states with Medicaid expansion, there was no improvement in timeliness of initiating care or stage at diagnosis.

Textbook outcome after pancreatoduodenectomy and distal pancreatectomy with postoperative hyperamylasemia-a propensity score matching analysis

PURPOSE

Postoperative serum hyperamylasemia (POH) is a part of the new, increasingly highlighted, definition for postpancreatectomy pancreatitis (PPAP). This study aimed to analyze whether the biochemical changes of PPAP are differently associated with postoperative complications after distal pancreatectomy (DP) compared with pancreatoduodenectomy (PD). The textbook outcome (TO) was used as a summary measure to capture real-world data.

METHODS

The data were retrospectively extracted from a prospective clinical database. Patients with POH, defined as levels above our institution's upper limit of normal on postoperative day 1, after DP and the corresponding propensity score-matched cohort after PD were evaluated on postoperative complications by using logistic regression analyses.

RESULTS

We analyzed 723 patients who underwent PD and DP over a period of 9 years. After propensity score matching, 384 patients (192 patients in each group) remained. POH was observed in 78 (41.1%) and 74 (39.4%) after PD and DP correspondingly. There was a significant increase of postoperative complications in the PD group: Clavien-Dindo classification system ≥3 (P < .01 vs P = .71), clinically relevant postoperative pancreatic fistula (P < .001 vs P = .2), postpancreatectomy hemorrhage (P < .001 vs P = .11), and length of hospital stay (P < .001 vs P = .69) if POH occurred compared with in the DP group. TO was significantly unlikely in cases with POH after PD compared with DP (P > .001 vs P = .41). Furthermore, POH was found to be an independent predictor for missing TO after PD (odds ratio [OR], 0.29; 95% CI, 0.14-0.60; P < .001), whereas this was not observed in patients after DP (OR, 0.53; 95% CI, 0.21-1.33; P = .18).

CONCLUSION

As a part of the definition for PPAP, POH is a predictive indicator associated with postoperative complications after PD but not after DP.

Is surgical treatment of hepatocellular carcinoma at high-volume centers worth the additional cost?

BACKGROUND

Case volume has been associated with improved outcomes for patients undergoing treatment for hepatocellular carcinoma, often with higher hospital expenditures. We sought to define the cost-effectiveness of hepatocellular carcinoma treatment at high-volume centers.

METHODS

Patients diagnosed with hepatocellular carcinoma from 2013 to 2017 were identified from Medicare Standard Analytic Files. High-volume centers were defined as the top decile of facilities performing hepatectomies in a year. A multivariable generalized linear model with gamma distribution and a restricted mean survival time model were used to estimate costs and survival differences relative to high-volume center status. The incremental cost-effectiveness ratio was used to define the additional cost incurred for a 1-year incremental gain in survival.

RESULTS

Among 13,666 patients, 8,467 (62.0%) were treated at high-volume centers. Median expenditure was higher ($19,148, interquartile range $15,280-$29,128) among patients treated at high-volume centers versus low-volume centers ($18,209, interquartile range $14,959-$29,752). Despite similar median length-of-stay (6 days, interquartile range 4-9), a slightly higher proportion of patients were discharged to home from high-volume centers (n = 4,903, 57.9%) versus low-volume centers (n = 2,868, 55.2%) (P = .002). A 0.14-year (95% confidence interval 0.06-0.22) (1 month and 3 weeks) survival benefit was associated with an incremental cost of $1,070 (95% confidence interval $749-$1,392) among patients undergoing surgery at high-volume centers. The incremental cost-effectiveness ratio for treatment at a high-volume center was $7,951 (95% confidence interval $4,236-$21,217) for an additional year of survival, which was below the cost-effective threshold of $21,217.

CONCLUSION

Surgical care at high-volume centers offers the potential to deliver cancer care in a more cost-effective and value-based manner.

Distal Pancreatectomy: Extent of Resection Determines Surgical Risk Categories

BACKGROUND

Recently, subclassification of pancreatoduodenectomy in 4 differing types has been reported, because additional major vascular and multivisceral resections have been shown to be associated with an increased risk of postoperative morbidity and mortality.

OBJECTIVE

To classify distal pancreatectomy (DP) based on the extent of resection and technical difficulty and to evaluate postoperative outcomes with regards to this classification system.

METHODS

All consecutive patients who had undergone DP between 2001 and 2020 in a high-volume pancreatic surgery center were included in this study. DPs were subclassified into 4 distinct categories reflecting the extent of resection and technical difficulty, including standard DP (type 1), DP with venous (type 2), multivisceral (type 3), or arterial resection (type 4). Patient characteristics, perioperative data, and postoperative outcomes were analyzed and compared among the 4 groups.

RESULTS

A total of 2135 patients underwent DP. Standard DP was the most frequently performed procedure (64.8%). The overall 90-day mortality rate was 1.6%. Morbidity rates were higher in patients with additional vascular or multivisceral resections, and 90-day mortality gradually increased with the extent of resection from standard DP to DP with arterial resection (type 1: 0.7%; type 2: 1.3%; type 3: 3%; type 4: 8.7%; P <0.0001). Multivariable analysis confirmed the type of DP as an independent risk factor for 90-day mortality.

CONCLUSIONS

Postoperative outcomes after DP depend on the extent of resection and correlate with the type of DP. The implementation of the 4-type classification system allows standardized reporting of surgical outcomes after DP improving comparability of future studies.

Impact of facility volume on survival in primary endoscopic surgery for sinonasal squamous cell carcinoma

OBJECTIVES

To evaluate the impact of facility volume on outcomes following primary endoscopic surgical management of sinonasal squamous cell carcinoma (SNSCC).

METHODS

The 2010-2016 National Cancer DataBase (NCDB) was queried for patients diagnosed with T1-T4a SNSCC surgically treated endoscopically as the primary treatment modality. Factors associated with overall survival (OS) were evaluated, including facility volume.

RESULTS

A total of 330 patients who underwent endoscopic surgical management of SNSCC were treated at 356 unique facilities designated as either low-volume (LVC; treating 1-2 cases; 0-75th percentile), intermediate-volume centers (IVC; 3-4 cases total; 75th-90th percentile), or 144 high-volume (HVC; treating 5+ cases total; >90th percentile) centers. HVC treated patients with higher T staging (42.1 % vs. 29.8 %) and tumors in the maxillary sinus (26.9 % vs. 13.2 %) and ethmoid sinus (10.3 % vs. ≤8.3 %), while LVCs treated lower T stage tumors (70.2 % vs. 57.9 %) and tumors that were located in the nasal cavity (70.2-78.5 % vs. 62.8 %). On multivariable analysis, factors associated with decreased OS included higher T stage (T3/T4a vs. T1/T2; OR 1.92, 95 % CI 1.06-3.47) and older age (>65 vs. <65; OR 2.69, 95 % CI 1.62-4.49). Cases treated at high-volume centers were not associated with a higher likelihood of OS when compared to low-volume centers (OR 0.70, 95 % CI 0.36-1.35).

CONCLUSIONS

HVC are treating more primary tumors of the maxillary and ethmoid sinuses and tumors with higher T stages with endoscopic approaches, although this does not appear to be associated with increased OS.

SHORT SUMMARY

Sinonasal squamous cell carcinoma (SNSCC) presents late in disease process with poor prognosis. We investigated the impact of facility volume on outcomes following endoscopic treatment of SNSCC. High-volume centers treat more advanced and complex disease with comparable OS.

Presence of underlying cirrhosis is associated with increased in-hospital mortality and length of stay following pancreatoduodenectomy

BACKGROUND

Patient- and hospital-level factors associated with outcomes following pancreatoduodenectomy (PD) are well established. However, despite theoretical disruption in hepatopetal flow, the impact of cirrhosis on in-hospital mortality following PD is not well-studied. The objective of this study was to evaluate in-hospital mortality, length of stay (LOS), and post-discharge disposition in patients with cirrhosis undergoing PD.

METHODS

A retrospective analysis of the National Inpatient Sample (January 2002-August 2015) was conducted identifying patients undergoing PD. Using previously validated ICD-9-CM codes, patients were stratified into presence and absence of cirrhosis. Factors associated with in-hospital mortality following PD were analyzed adjusting for patient- and hospital-level factors. Following PD were analyzed after adjusting for patient- and hospital-level factors.

RESULTS

In 16,344 patients that underwent PD, 203 (1.2 %) patients had underlying cirrhosis prior to resection. Overall in-hospital mortality following PD was significantly worse in the cirrhosis cohort (11.3 % vs. 3.6 %, p < 0.001). Patients with underlying cirrhosis were less likely to be discharged home (73.9 % vs. 83.2 %, p < 0.001) and had a longer median LOS (12.0 vs. 10.0 days, p = 0.001).

CONCLUSION

The presence of underlying cirrhosis is associated with increased in-hospital mortality, longer LOS, and decreased likelihood of home discharge following PD. Given the prohibitive risks, PD should not be performed in patients with underlying cirrhosis.

Supply and demand of hepatopancreatobiliary surgeons in the United States

BACKGROUND

Hepatopancreatobiliary (HPB) surgery requires specialized training and adequate case volumes to maintain procedural proficiency and optimal outcomes. Studies of individual HPB surgeon supply related to annual HPB case demand are sparse. This study assesses the supply and demand of the HPB surgical workforce in the United States (US).

METHODS

The National Inpatient Sample (NIS) was queried from 1998-2019 to estimate the number of HPB procedures performed. To approximate the number of HPB surgeons, models based on previous HPB workforce publications were employed. We then calculated the number of HPB surgeons needed to maintain volume-outcome thresholds at current reported levels of centralization.

RESULTS

In 2019, approximately 37,335 patients underwent inpatient HPB procedures in the US, while an estimated 905-1191 HPB surgeons were practicing. Assuming 50% centralization and an optimal volume-outcome threshold of 24 HPB cases-per-year, only 778 HPB surgeons were needed. Without adjustment in centralization, by 2030 there will be a demand of fewer than 12 annual cases per HPB surgeon.

CONCLUSION

The current supply of HPB surgeons may exceed demand in the United States. Without alteration in training pathways or improved care centralization, by 2030, there will be insufficient HPB case volume per surgeon to maintain published volume-outcome standards.

Pancreatic surgery outcomes: multicentre prospective snapshot study in 67 countries

BACKGROUND

Pancreatic surgery remains associated with high morbidity rates. Although postoperative mortality appears to have improved with specialization, the outcomes reported in the literature reflect the activity of highly specialized centres. The aim of this study was to evaluate the outcomes following pancreatic surgery worldwide.

METHODS

This was an international, prospective, multicentre, cross-sectional snapshot study of consecutive patients undergoing pancreatic operations worldwide in a 3-month interval in 2021. The primary outcome was postoperative mortality within 90 days of surgery. Multivariable logistic regression was used to explore relationships with Human Development Index (HDI) and other parameters.

RESULTS

A total of 4223 patients from 67 countries were analysed. A complication of any severity was detected in 68.7 per cent of patients (2901 of 4223). Major complication rates (Clavien-Dindo grade at least IIIa) were 24, 18, and 27 per cent, and mortality rates were 10, 5, and 5 per cent in low-to-middle-, high-, and very high-HDI countries respectively. The 90-day postoperative mortality rate was 5.4 per cent (229 of 4223) overall, but was significantly higher in the low-to-middle-HDI group (adjusted OR 2.88, 95 per cent c.i. 1.80 to 4.48). The overall failure-to-rescue rate was 21 per cent; however, it was 41 per cent in low-to-middle- compared with 19 per cent in very high-HDI countries.

CONCLUSION

Excess mortality in low-to-middle-HDI countries could be attributable to failure to rescue of patients from severe complications. The authors call for a collaborative response from international and regional associations of pancreatic surgeons to address management related to death from postoperative complications to tackle the global disparities in the outcomes of pancreatic surgery (NCT04652271; ISRCTN95140761).

Defining Volume Targets for Regionalization of Pancreaticoduodenectomy, Esophagectomy, and Major Lung Resection Centers to Improve Oncologic and Surgical Outcomes

BACKGROUND

Performance of complex cancer surgeries at high-volume (HV) centers has been shown to reduce operative mortality. However, the case volume threshold that should be used to define HV centers is unknown. In this study, we determined thresholds to define HV pancreaticoduodenectomy, esophagectomy, and major lung resection centers based on clinical parameters. Then, we assessed the association of hospital volume with oncologic outcomes and overall survival.

METHODS

We identified adult NCDB patients undergoing pancreaticoduodenectomy, esophagectomy, and major lung resections between 2004 and 2015. Multivariable models with restricted cubic splines were built to predict 5-year overall survival for each surgery group according to average yearly case volume, adjusting for demographic and clinicopathologic factors. The change point procedure was then used to identify volume cut-points for each surgery type.

RESULTS

We identified the following thresholds to define HV status: 25 cases/year for pancreaticoduodenectomy; 18 cases/year for esophagectomy; and 54 cases/year for major lung resections. For all surgery types, treatment at a HV center was associated with an increased likelihood of R0 resection and adequate lymph node evaluation. HV centers had significantly decreased 30- and 90-day, postoperative mortality after adjusting for age, sex, race, comorbidities, histology, and stage. An overall survival benefit also was observed for patients undergoing resections at HV centers.

CONCLUSIONS

Using novel methodology, our study identified volume thresholds for HV pancreaticoduodenectomy, esophagectomy, and major lung resection centers that were associated with improved oncologic outcomes and overall survival. These definitions of HV centers should be considered when evaluating regionalization of complex cancer care.

Urban-Rural Differences in Receipt of Cancer Surgery at High-Volume Hospitals and Sensitivity to Hospital Volume Thresholds

Methods for identifying high-volume hospitals affect conclusions about rural cancer care access.

Pancreatic Cancer: A Review of Current Treatment and Novel Therapies

Pancreatic cancer is one of the leading causes for cancer-related deaths in the United States. Majority of patients present with unresectable or metastatic disease. For those that present with localized disease, a multidisciplinary approach is necessary to maximize survival and optimize outcomes. The quality and safety of surgery for pancreatic cancer have improved in recent years with increasing adoption of minimally invasive techniques and surgical adjuncts. Systemic chemotherapy has also evolved to impact survival. It is now increasingly being utilized in the neoadjuvant setting, often with concomitant radiation. Increased utilization of genomic testing in metastatic pancreatic cancer has led to better understanding of their biology, thereby allowing clinicians to consider potential targeted therapies. Similarly, targeted agents such as PARP inhibitors and immune checkpoint- inhibitors have emerged with promising results. In summary, pancreatic cancer remains a disease with poor long-term survival. However, recent developments have led to improved outcomes and have changed practice in the past decade. This review summarizes current practices in pancreatic cancer treatment and the milestones that brought us to where we are today, along with emerging therapies.

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.

Nationwide Outcomes of Pancreaticoduodenectomy for Pancreatic Malignancies: Center Volume Matters

BACKGROUND

Complex surgeries such as pancreaticoduodenectomies (PD) have been shown to have better outcomes when performed at high-volume centers (HVCs) compared to low-volume centers (LVCs). Few studies have compared these factors on a national level. The purpose of this study was to analyze nationwide outcomes for patients undergoing PD across hospital centers with different surgical volumes.

METHODS

The Nationwide Readmissions Database (2010-2014) was queried for all patients who underwent open PD for pancreatic carcinoma. High-volume centers were defined as hospitals where 20 or more PDs were performed per year. Sociodemographic factors, readmission rates, and perioperative outcomes were compared before and after propensity score-matched analysis (PSMA) for 76 covariates including demographics, hospital factors, comorbidities, and additional diagnoses. Results were weighted for national estimates.

RESULTS

A total of 19,810 patients were identified with age 66 ± 11 years. There were 6,840 (35%) cases performed at LVCs, and 12,970 (65%) at HVCs. Patient comorbidities were greater in the LVC cohort, and more PDs were performed at teaching hospitals in the HVC cohort. These discrepancies were controlled for with PSMA. Length of stay (LOS), mortality, invasive procedures, and perioperative complications were greater in LVCs when compared to HVCs before and after PSMA. Additionally, readmission rates at one year (38% vs 34%, P < .001) and readmission complications were greater in the LVC cohort.

CONCLUSIONS

Pancreaticoduodenectomy is more commonly performed at HVCs, which is associated with less complications and improved outcomes compared to LVCs.

The Impact of Medicaid Expansion on Early-Stage Pancreatic Adenocarcinoma at High- Versus Low-Volume Facilities

INTRODUCTION

While Medicaid Expansion (ME) has improved healthcare access, disparities in outcomes after volume-dependent surgical care persist. We sought to characterize the impact of ME on postoperative outcomes among patients undergoing resection for pancreatic ductal adenocarcinoma (PDAC) at high-volume (HVF) versus low-volume (LVF) facilities.

METHODS

Patients who underwent resection for PDAC were identified from the National Cancer Database (NCDB; 2011-2018). HVF was defined as ≥20 resections/year. Patients were divided into pre- and post-ME cohorts, and the primary outcome was textbook oncologic outcomes (TOO). Difference-in-difference (DID) analysis was used to assess changes in TOO achievement among patients living in ME versus non-ME states.

RESULTS

Among 33,764 patients who underwent resection of PDAC, 19.1% (n = 6461) were treated at HVF. Rates of TOO achievement were higher at HVF (HVF: 45.7% vs. LVF: 32.8%; p < 0.001). On multivariable analysis, undergoing surgery at HVF was associated with higher odds of achieving TOO (odds ratio [OR] 1.60, 95% confidence interval [CI] 1.49-1.72) and improved overall survival (OS) [hazard ratio (HR) 0.96, 95% CI 0.92-0.99]. Compared with patients living in non-ME states, individuals living in ME states were more likely to achieve TOO on adjusted DID analysis (5.4%, p = 0.041). Although rates of TOO achievement did not improve after ME at HVF (3.7%, p = 0.574), ME contributed to markedly higher rates of TOO among patients treated at LVF (6.7%, p = 0.022).

CONCLUSIONS

Although outcomes for PDAC remain volume-dependent, ME has contributed to significant improvement in TOO achievement among patients treated at LVF. These data highlight the impact of ME on reducing disparities in surgical outcomes relative to site of care.

Excellence in forensic psychiatry services: international survey of qualities and correlates

BACKGROUND

Excellence is that quality that drives continuously improving outcomes for patients. Excellence must be measurable. We set out to measure excellence in forensic mental health services according to four levels of organisation and complexity (basic, standard, progressive and excellent) across seven domains: values and rights; clinical organisation; consistency; timescale; specialisation; routine outcome measures; research and development.

AIMS

To validate the psychometric properties of a measurement scale to test which objective features of forensic services might relate to excellence: for example, university linkages, service size and integrated patient pathways across levels of therapeutic security.

METHOD

A survey instrument was devised by a modified Delphi process. Forensic leads, either clinical or academic, in 48 forensic services across 5 jurisdictions completed the questionnaire.

RESULTS

Regression analysis found that the number of security levels, linked patient pathways, number of in-patient teams and joint university appointments predicted total excellence score.

CONCLUSIONS

Larger services organised according to stratified therapeutic security and with strong university and research links scored higher on this measure of excellence. A weakness is that these were self-ratings. Reliability could be improved with peer review and with objective measures such as quality and quantity of research output. For the future, studies are needed of the determinants of other objective measures of better outcomes for patients, including shorter lengths of stay, reduced recidivism and readmission, and improved physical and mental health and quality of life.

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.

Laparoscopic Versus Open Pancreatoduodenectomy in Patients With Periampullary Tumors: A Systematic Review and Meta-analysis

OBJECTIVE

To conduct a systematic review and meta-analysis of randomized controlled trials compared laparoscopic pancreatoduodenectomy (LPD) versus open pancreatoduodenectomy (OPD) in patients with periampullary tumors.

BACKGROUND

LPD has gained attention; however, its safety and efficacy versus OPD remain debatable.

METHODS

We searched PubMed and Embase. Primary outcomes were the length of hospital stay (LOS) (day), Clavien-Dindo grade ≥III complications, and 90-day mortality. Secondary outcomes were blood loss (milliliter), blood transfusion, duration of operation (minute), readmission, reoperation, comprehensive complication index score, bile leak, gastrojejunostomy or duodenojejunostomy leak, postoperative pancreatic fistula, postpancreatectomy hemorrhage, delayed gastric emptying, surgical site infection, intra-abdominal infection, number of harvested lymph nodes, and R0 resection. Pooled odds ratio (OR) or mean difference (MD) of data was calculated using the random-effect model. The grading of recommendations, assessment, development and evaluation approach was used for grading the level of evidence.

RESULTS

Four randomized controlled trials yielding 818 patients were included, of which 411 and 407 patients underwent LPD and OPD, respectively. The meta-analysis concluded that 2 approaches were similar, except in the LPD group, the LOS tended to be shorter [MD=-2.54 (-5.17, 0.09), P =0.06], LOS in ICU was shorter [MD=-1 (-1.8, -0.2), P =0.01], duration of operation was longer [MD=75.16 (23.29, 127.03), P =0.005], blood loss was lower [MD=-115.40 (-152.13, -78.68), P <0.00001], blood transfusion was lower [OR=0.66 (0.47, 0.92), P =0.01], and surgical site infection was lower [OR=0.35 (0.12, 0.96), P =0.04]. The overall certainty of the evidence was moderate.

CONCLUSIONS

Within the hands of highly skilled surgeons in high-volume centers, LPD is feasible and as safe and efficient as OPD.

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.

Perioperative and Oncological Outcomes of Robotic Versus Open Pancreaticoduodenectomy in Low-Risk Surgical Candidates: A Multicenter Propensity Score-Matched Study

OBJECTIVES

This study aimed to perform a multicenter comparison between robotic pancreaticoduodenectomy (RPD) and open pancreaticoduodenectomy (OPD).

BACKGROUND

Previous comparisons of RPD versus OPD have only been carried out in small, single-center studies of variable quality.

METHODS

Consecutive patients who underwent RPD (n = 1032) or OPD (n = 1154) at 7 centers in China between July 2012 and July 2020 were included. A 1:1 propensity score matching (PSM) was performed.

RESULTS

After PSM, 982 patients in each group were enrolled. The RPD group had significantly lower estimated blood loss (EBL) (190.0 vs 260.0 mL; P < 0.001), and a shorter postoperative 1length of hospital stay (LOS) (12.0 (9.0-16.0) days vs 14.5 (11.0-19.0) days; P < 0.001) than the OPD group. There were no significant differences in operative time, major morbidity including clinically relevant postoperative pancreatic fistula (CR-POPF), bile leakage, delayed gastric emptying, postoperative pancreatectomy hemorrhage (PPH), reoperation, readmission or 90-day mortality rates. Multivariable analysis showed R0 resection, CR-POPF, PPH and reoperation to be independent risk factors for 90-day mortality. Subgroup analysis on patients with pancreatic ductal adenocarcinoma (PDAC) (n = 326 in each subgroup) showed RPD had advantages over OPD in EBL and postoperative LOS. There were no significant differences in median disease-free survival (15.2 vs 14.3 months, P = 0.94) or median overall survival (24.2 vs 24.1 months, P = 0.88) between the 2 subgroups.

CONCLUSIONS

RPD was comparable to OPD in feasibility and safety. For patients with PDAC, RPD resulted in similar oncologic and survival outcomes as OPD.

Telemedicine and Pancreatic Cancer: A Systematic Review

Introduction: Pancreatic cancer requires a multidisciplinary approach in a high-volume center for all the steps of the diagnostic-therapeutic course. However, the most experienced centers are not evenly distributed throughout the country causing a real "health migration" that involves patients and families with relevant economic, time, and energy costs to bear. The COVID-19 pandemic had a deep impact on surgical and oncological care and the travel limits due to COVID-related restrictions, have delayed the care of cancer patient living far from the referral centers. In this scenario, several telemedicine approaches have been proposed to reduce the distance between clinicians and patients and to allow a fast and effective access to care even for patients distant from referral centers. The aim of the study is to analyze the evidence and describe the current utility of telemedicine tool for patients with pancreatic cancer. Methods: We systematically searched the literature in the following databases: Web of Science, PubMed, Scopus, and MEDLINE. The inclusion criteria were article describing a telemedicine intervention (virtual visits, telephone follow-up/counseling, mobile or online apps, telemonitoring) and focusing on adult patients with pancreatic cancer at any stage of the disease. Results: In total, 846 titles/abstracts were identified. Following quality assessment, the review included 40 studies. Telemedicine has been proposed in multiple clinical settings, demonstrating high levels of patient and health professional satisfaction. Conclusion: Successful telemedicine applications in patients with pancreatic cancer are telerehabilitation and nutritional assessment, remote symptom control, teledischarge after pancreatic surgery, tele-education and medical mentoring regarding pancreatic disease as well as telepathology.

Surgical outcome of a double versus a single pancreatoduodenectomy per operating day

BACKGROUND

For logistical reasons, some high-volume centers have developed surgical programs wherein 1 surgical team performs 2 pancreatoduodenectomies on a single day. It is unclear whether this practice has a negative impact on surgical outcome.

METHODS

We conuducted a retrospective analysis including all consecutive open pancreatoduodenectomies in a single high-volume center (2014-2021). Pancreatoduodenectomies were grouped as the first (pancreatoduodenectomy-1) or second (pancreatoduodenectomy-2) pancreatoduodenectomy on a single day (ie, paired pancreatoduodenectomies) and as pancreatoduodenectomy-3 whenever 1 pancreatoduodenectomy was performed per day (ie, unpaired). Patients undergoing minimally invasive procedures were excluded. The primary outcomes were major morbidity (ie, Clavien-Dindo grade ≥IIIa) and mortality.

RESULTS

Among 689 patients, 151 patients had undergone minimally invasive pancreatoduodenectomy, leaving 538 patients after open pancreatoduodenectomy for inclusion. The overall rate of major morbidity was 37.4% (n = 200/538) and in-hospital/30-day mortality 1.7% (n = 9/538). Overall, 136 (25.3%) patients were operated in 68 pancreatoduodenectomy-1/ pancreatoduodenectomy-2 pairs and 402 (74.7%) patients as unpaired pancreatoduodenectomy (pancreatoduodenectomy-3). No differences were found between pancreatoduodenectomy-1 and pancreatoduodenectomy-2 regarding the rates of major morbidity (35.3% vs 26.5%; P = .265) and mortality (1.5% vs 0%; P = .999). Between the 68 pancreatoduodenectomy-1/ pancreatoduodenectomy-2 pairs and the 402 unpaired pancreatoduodenectomies, the rates of major morbidity (30.9% vs 39.6%; P = .071) and mortality (0.7% vs 2.0%; P = .461) did not differ significantly. In multivariable logistic regression analysis, pancreatoduodenectomy-1 was not associated with major morbidity (odds ratio = 0.913 [95% confidence interval 0.515-1.620]; P = .756), whereas pancreatoduodenectomy-2 was associated with less major morbidity (odds ratio = 0.522 [95% confidence interval 0.277-0.983]; P = .045).

CONCLUSION

In a high-volume setting, performing 2 consecutive open pancreatoduodenectomies on a single operating day appears to be safe. This approach may be an option when logistically required.

Reappraisal of Malignant Risk Assessment for Small (≤20 mm) Non-functioning Pancreatic Neuroendocrine Tumors

BACKGROUND

Optimal management of non-functioning pancreatic neuroendocrine tumors (PanNETs) ≤20 mm is controversial. The biological heterogeneity of these tumors poses challenges when deciding between resection and observation.

METHODS

In this multicenter, retrospective cohort study, we analyzed all patients (n = 78) who underwent resection of non-functioning PanNETs ≤20 mm at three tertiary medical centers from 2004 to 2020 to assess the utility of preoperatively available radiological features and serological biomarkers of non-functioning PanNETs in choosing an optimal surgical indication. The radiological features included non-hyper-attenuation pattern on enhancement computed tomography (CT; hetero/hypo-attenuation) and main pancreatic duct (MPD) involvement, and serological biomarkers included elevation of serum elastase 1 and plasma chromogranin A (CgA) levels.

RESULTS

Of all small non-functioning PanNETs, 5/78 (6%) had lymph node metastasis, 11/76 (14%) were WHO grade II, and 9/66 (14%) had microvascular invasion; 20/78 (26%) had at least one of these high-risk pathological factors. In the preoperative assessment, hetero/hypo-attenuation and MPD involvement were observed in 25/69 (36%) and 8/76 (11%), respectively. Elevated serum elastase 1 and plasma CgA levels were observed in 1/33 (3%) and 0/11 (0%) patients, respectively. On multivariate logistic regression analysis, hetero/hypo-attenuation (odds ratio [OR] 6.1, 95% confidence interval [CI] 1.7-22.2) and MPD involvement (OR 16.8, 95% CI 1.6-174.3) were significantly associated with the high-risk pathological factors. The combination of the two radiological worrisome features correctly predicted non-functioning PanNETs with high-risk pathological factors, with about 75% sensitivity, 79% specificity, and 78% accuracy.

CONCLUSIONS

This combination of radiological worrisome features can accurately predict non-functioning PanNETs that may require resection.

Predictors of hospital bypass for rural residents seeking common elective surgery

BACKGROUND

Surgical bypass occurs when rural residents receive surgical care at a nonlocal hospital. Given limited knowledge of current bypass rates, we evaluated rates and predictors of bypass for common procedures.

METHODS

We used 2014 to 2016 all-payer claims data from the Healthcare Cost and Utilization Project State Inpatient Databases to study rural patients from 13 states who underwent 1 of 11 common elective surgical procedures. Bypass was measured by whether a patient received elective surgical care at the closest hospital offering the requested procedure or another nonlocal hospital. Bypass probability was then modeled as a function of patient-level and hospital-level characteristics.

RESULTS

Of the 121,297 rural elective surgery visits in our sample, 78,268 (64.5%) bypassed their local hospital. Bypass rate was greatest for coronary artery bypass graft or valve replacement (74.8%) and lowest for laparoscopic cholecystectomy (53.7%). In addition, average bypass rate was greatest for surgeries with the highest risk of intraoperative blood loss and postoperative complications. The probability of bypass significantly (P < .001) increased for patients who were younger, privately insured, and lived farther from the closest hospital. In addition, the probability of bypass significantly (P < .001) increased for patients whose local hospital had fewer full-time equivalents, lower operating margin, and fewer recommendations from previous patients.

CONCLUSION

Among rural patients seeking elective surgery, bypass of the local hospital was common among both low-risk and high-risk procedures. These findings suggest that there is a substantial amount of bypass, which may negatively impact a hospital's financial performance and, hence, wellbeing of the local community.

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.

Simultaneous Heart-Kidney Transplant-Does Hospital Experience With Heart Transplant or Kidney Transplant Have a Greater Impact on Patient Outcomes?

High institutional transplant volume is associated with improved outcomes in isolated heart and kidney transplant. The aim of this study was to assess trends and outcomes of simultaneous heart-kidney transplant (SHKT) nationally, as well as the impact of institutional heart and kidney transplant volume on survival. All adult patients who underwent SHKT between 2005-2019 were identified using the United Network for Organ Sharing (UNOS) database. Annual institutional volumes in single organ transplant were determined. Univariate and multivariable analyses were conducted to assess the impact of demographics, comorbidities, and institutional transplant volumes on 1-year survival. 1564 SHKT were identified, increasing from 54 in 2005 to 221 in 2019. In centers performing SHKT, median annual heart transplant volume was 35.0 (IQR 24.0-56.0) and median annual kidney transplant volume was 166.0 (IQR 89.5-224.0). One-year survival was 88.4%. In multivariable analysis, increasing heart transplant volume, but not kidney transplant volume, was associated with improved 1-year survival. Increasing donor age, dialysis requirement, ischemic times, and bilirubin were also independently associated with reduced 1-year survival. Based on this data, high-volume heart transplant centers may be better equipped with managing SHKT patients than high-volume kidney transplant centers.

Pancreaticoduodenectomy with right hemicolectomy for advanced malignancy: a single UK hepatopancreaticobiliary centre experience

AIM

Locally advanced intestinal neoplasms including colon cancer may require radical en bloc pancreaticoduodenectomy and right hemicolectomy (PD-RC) to achieve curative, margin-negative resection, but the safety and benefit of this uncommon procedure has not been established. The Association of Coloproctology of Great Britain and Ireland IMPACT initiative has also highlighted a lack of awareness about current services available within the UK for patients with advanced colorectal cancer and concerns about low-volume centres managing complex cases. Thus, we aimed to review the feasibility, safety and long-term outcomes of this procedure at a single high-volume hepatopancreaticobiliary surgery unit in the UK.

METHOD

A retrospective cohort study was performed using a database of all consecutive patients with intestinal cancer who had been referred to our regional advanced multidisciplinary team and undergone PD-RC in a 7-year period (2013-2020). Clinico-pathological and outcome data were reviewed.

RESULTS

Ten patients (mean age 54 ± 13, 8/10 men) were identified. Final histology revealed the primary tumour sites were colon (n = 7) and duodenum (n = 3). R0 resection was achieved in all cases. The major complication rate (Clavien-Dindo ≥ 3) was 10% (1/10) with no deaths within 90 days of surgery. The Kaplan-Meier estimated 5-year overall survival was 83.3% (95% CI 58.3%-100%). Univariate survival analysis identified perineural invasion and extra-colonic origin as predictors of poor survival (log-rank P < 0.05).

CONCLUSION

En bloc PD-RC for locally advanced intestinal cancer can be performed safely with a high proportion of margin-negative resections and resultant long-term survival in carefully selected patients.

Structural and Socio-Spatial Determinants Influencing Care and Survival of Patients with a Pancreatic Adenocarcinoma: Results of the PANDAURA Cohort

Background and aims: Pancreatic cancer is highly lethal and often diagnosed at an advanced stage. This cohort study analyzes the impact of care pathways, delays, and socio-spatial determinants on pancreatic cancer patients’ diagnosis, treatment, and prognosis. Method: Patients with pancreatic adenocarcinoma newly diagnosed at all stages between January and June 2016 in the AuRA French region were included. The influence on survival of delays of care, healthcare centers’ expertise, and socio-spatial determinants was evaluated. Results: Here, 538 patients were included in 76 centers including 116 patients (21.8%) with resectable, 64 (12.0%) borderline-resectable, 147 (27.6%) locally-advanced tumors, and 205 (38.5%) with metastatic disease. A delay between first symptoms and CT scans did not statistically influence overall survival (OS). In resected patients, OS was significantly higher in centers with more than 20 surgeries (HR<5 surgeries/year = 2.236 and HR5-20 surgeries/year = 1.215 versus centers with > 20 surgeries/year p = 0.0081). Regarding socio-spatial determinants, patients living in municipalities with greater access to a general practitioner (HR = 1.673, p = 0.0153) or with a population density below 795.1 people/km2 (HR = 1.881, p = 0.0057) were significantly more often resectable. Conclusion: This cohort study supports the pivotal role of general practitioner in cancer care and the importance of the centralization of pancreatic surgery to optimize pancreatic cancer patients’ care and outcomes. However, delays of care did not impact patient survival.

Preoperative biliary drainage in severely jaundiced patients with pancreatic head cancer: A retrospective cohort study

BACKGROUND

Guidelines recommend against preoperative biliary drainage (PBD) in patients with pancreatic head cancer if bilirubin levels are <250 μmol/l. However, patients with higher bilirubin levels undergo PBD, despite the lack of supporting evidence. This study aims to evaluate outcomes in patients with a bilirubin level ≥250 and < 250.

METHODS

Patients were identified from databases of 3 centers. Outcomes were compared in patients with a bilirubin level ≥250 versus <250 both at the time of diagnosis and directly prior to surgery.

RESULTS

244 patients were included. PBD was performed in 64% (123/191) with bilirubin <250 at diagnosis and 91% (48/53) with bilirubin ≥250. PBD technical success (83% vs. 81%, p = 0.80) and PBD related complications (33% vs. 29%, p = 0.60) did not differ between these groups. Analyzing bilirubin levels ≥250 versus <250 directly prior to surgery, no differences in severe postoperative complications and mortality were found.

CONCLUSIONS

In patients with a pancreatic head cancer, PBD technical success and complications, and severe postoperative complications did not differ between patients with a bilirubin level ≥250 and < 250. Our study does not support a different approach regarding PBD in patients with severe jaundice.

Robotic versus open pancreaticoduodenectomy for distal cholangiocarcinoma: a multicenter propensity score-matched study

BACKGROUND

Pancreatoduodenectomy is the only potentially curative treatment for distal cholangiocarcinoma (DCC). In this study, we sought to compare the perioperative and oncological outcomes of robotic pancreaticoduodenectomy (RPD) and open pancreaticoduodenectomy (OPD) based on a multicenter propensity score-matched study.

METHODS

Consecutive patients with DCC who underwent RPD or OPD from five centers in China between January 2014 and June 2019 were included. A 1:1 propensity score matching (PSM) was performed. Univariable and multivariable Cox regression analyses were used to identify independent prognosis factors for overall survival (OS) and recurrence-free survival (RFS) of these patients.

RESULTS

A total of 217 patients and 228 patients underwent RPD and OPD, respectively. After PSM, 180 patients in each group were enrolled. There were no significant differences in operative time, lymph node harvest, intraoperative transfusion, vascular resection, R0 resection, postoperative major morbidity, reoperation, 90-day mortality, and long-term survival between the two groups before and after PSM. Whereas, compared with the OPD group, the RPD group had significantly lower estimated blood loss (150.0 ml vs. 250.0 ml; P < 0.001), and a shorter postoperative length of stay (LOS) (12.0 days vs. 15.0 days; P < 0.001). Multivariable analysis showed carbohydrate antigen 19-9 (CA19-9), R0 resection, N stage, perineural invasion, and tumor differentiation significantly associated with OS and RFS of these patients.

CONCLUSIONS

RPD was comparable to OPD in feasibility and safety. For patients with DCC, RPD resulted in similar oncologic and survival outcomes as OPD.

Intraoperative visualisation of pancreatic leakage (ViP): study protocol for an IDEAL Stage I Post Market Clinical Study

INTRODUCTION

Pancreatic resections are an important field of surgery worldwide to treat a variety of benign and malignant diseases. Postoperative pancreatic fistula (POPF) remains a frequent and critical complication after partial pancreatectomy and affects up to 50% of patients. POPF increases mortality, prolongs the postoperative hospital stay and is associated with a significant economic burden. Despite various scientific approaches and clinical strategies, it has not yet been possible to develop an effective preventive tool. The SmartPAN indicator is the first surgery-ready medical device for direct visualisation of pancreatic leakage already during the operation. Applied to the surface of pancreatic tissue, it detects sites of biochemical leak via colour reaction, thereby guiding effective closure and potentially mitigating POPF development.

METHODS AND ANALYSIS

The ViP trial is a prospective single-arm, single-centre first in human study to collect data on usability and confirm safety of SmartPAN. A total of 35 patients with planned partial pancreatectomy will be included in the trial with a follow-up of 30 days after the index surgery. Usability endpoints such as adherence to protocol and evaluation by the operating surgeon as well as safety parameters including major intraoperative and postoperative complications, especially POPF development, will be analysed.

ETHICS AND DISSEMINATION

Following the IDEAL-D (Idea, Development, Exploration, Assessment, and Long term study of Device development and surgical innovation) framework of medical device development preclinical in vitro, porcine in vivo, and human ex vivo studies have proven feasibility, efficacy and safety of SmartPAN. After market approval, the ViP trial is the IDEAL Stage I trial to investigate SmartPAN in a clinical setting. The study has been approved by the local ethics committee as the device is used exclusively within its intended purpose. Results will be published in a peer-reviewed journal. The study will provide a basis for a future randomised controlled interventional trial to confirm clinical efficacy of SmartPAN.

TRIAL REGISTRATION NUMBER

German Clinical Trial Register DRKS00027559, registered on 4 March 2022.

Serum lipase on postoperative day one is a strong predictor of clinically relevant pancreatic fistula after pancreaticoduodenectomy: A retrospective cohort

BACKGROUND

Increased postoperative serum amylase has been recently reported to be associated with increased postoperative morbidity, but studies on postoperative serum lipase are limited. The aim of this study was to evaluate the value of postoperative serum lipase in predicting clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD).

METHOD

A retrospective analysis was performed on 212 patients who underwent PD from September 2018 and March 2021, focusing on the association between postoperative day (POD) 1 serum lipase and CR-POPF.

RESULTS

Overall, 108 (50.9%) patients had elevated serum lipase levels (>68 U/L) on POD 1. Patients with elevated serum lipase exhibited a significantly higher incidence of CR-POPF (37.0% vs. 6.7%, p < 0.001). Receiver operating characteristic (ROC) analyses showed improved diagnostic accuracy for POD 1 serum lipase compared with POD 1 serum amylase in predicting CR-POPF (AUC: 0.801 vs. 0.745, p = 0.029). Elevated serum lipase on POD 1 and elevated serum CRP on POD 3 were identified as independent predictors of CR-POPF. A simple early postoperative model, consisting of POD 1 serum lipase levels and POD 3 serum CRP levels, showed good discrimination (AUC 0.76, 95% CI 0.69-0.83) to identify the onset of CR-POPF.

CONCLUSION

Serum lipase on POD 1 outperformed serum amylase on POD 1 in predicting CR-POPF after PD. The combination of POD 1 serum lipase and POD 3 serum CRP provides a reliable predicting model for CR-POPF.

Contemporary outcomes of pancreaticoduodenectomy for benign and precancerous cystic lesions

BACKGROUND

The decision to undertake pancreaticoduodenectomy for benign and precancerous lesions has historically relied on outcomes data from operations for cancer. We aimed to describe risks for these specific patients and identify the highest risk groups.

METHODS

The ACS-NSQIP pancreatic targeted data was queried for pancreaticoduodenectomies for benign and pre-cancerous neoplasms from 2014 to 2018. Baseline characteristics, operative techniques and outcomes were examined. Multivariate regression was performed to identify predictors of major complications.

RESULTS

748 patients underwent pancreaticoduodenectomy for (n = 541,72.3%) IPMN, (n = 87,11.6%) MCN, (n = 78,10.4%) serous cystadenoma, and (n = 42,5.6%) solid pseudopapillary neoplasm. Median LOS was 8 days. Major complications (n = 135,18.0%), non-home discharges (n = 83,11.1%) and readmissions (n = 153,20.5%) occurred frequently. In patients ≥ 80 years of age (n = 37), major complications (n = 11,29.7%) and non-home discharge (n = 9,24.3%) were quite common. 5-item modified frailty index ≥ 0.4 (OR 1.84,95%CI 1.06-3.19,p = 0.030), Male sex (OR 1.729,95%CI 1.152-2.595,p = 0.008), Age ≥ 65 (OR 1.63,95%CI 1.05-2.54,p = 0.29) and African-American race (OR 2.50,95%CI 1.22-5.16,p = 0.013) were independent predictors of major morbidity.

CONCLUSIONS

Pancreaticoduodenectomies in this setting have high rates of major complications. Morbidity extends beyond the index hospitalization, with frequent readmission and non-home discharge. Patient specific factors, rather than technical or disease factors predicted outcomes. In certain patients, particularly those older than 80, the morbidity of this operation may exceed the cancer prevention benefits.

Blueprint For Safe Transition From a Low- to High-Volume Pancreatic Surgery Center

We describe a straightforward model to implement a high volume specialty surgery program at a community hospital. Using pancreatic surgery as an example, we employed published processes in three arenas. First, mandatory multidisciplinary tumor board presentations captured all the patients considered for surgery. Then, perioperative protocols using tools such as enhanced recovery and teamwork in the perioperative arena created a reproducible and safe environment for complex surgery. We critically reviewed all complications using the Clavien-Dindo methodology, and confirmed our favorable outcomes via the targeted NSQIP program. These standard steps can be used for implementation of a new complex surgical procedure.

Institutional case volume and mortality after aortic and mitral valve replacement: a nationwide study in two Korean cohorts

Background

There are only a handful of published studies regarding the volume-outcome relationship in heart valve surgery. We evaluated the association between institutional case volume and mortality after aortic valve replacement (AVR) and mitral valve replacement (MVR).

Methods

Two separate cohorts of all adults who underwent AVR or MVR, respectively, between 2009 and 2016 were analyzed using a Korean healthcare insurance database. Hospitals performing AVRs were divided into three groups according to the average annual case volume: the low- (< 20 cases/year), medium- (20–70 cases/year), and high-volume centers (> 70 cases/year). Hospitals performing MVRs were also grouped as the low- (< 15 cases/year), medium- (15–40 cases/year), or high-volume centers (> 40 cases/year). In-hospital mortality after AVR or MVR were compared among the groups.

Results

In total, 7875 AVR and 5084 MVR cases were analyzed. In-hospital mortality after AVR was 8.3% (192/2318), 4.0% (84/2102), and 2.6% (90/3455) in the low-, medium-, and high-volume centers, respectively. The adjusted risk was higher in the low- (OR 2.31, 95% CI 1.73–3.09) and medium-volume centers (OR 1.53, 95% CI 1.09–2.15) compared to the high-volume centers. In-hospital mortality after MVR was 9.3% (155/1663), 6.3% (94/1501), and 2.9% (56/1920) in the low-, medium-, and high-volume centers, respectively. Compared to the high-volume centers, the medium- (OR 1.97, 95% CI 1.35–2.88) and low-volume centers (OR 2.29, 95% CI 1.60–3.27) showed higher adjusted risk of in-hospital mortality.

Conclusions

Lower case volume is associated with increased in-hospital mortality after AVR and MVR. The results warrant a comprehensive discussion regarding regionalization/centralization of cardiac valve replacements to optimize patient outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-022-01945-0.

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.

Patterns of mortality after pancreatoduodenectomy: A root cause, day-to-day analysis

BACKGROUND

Mortality is consistently reported as an outcome metric in pancreatic surgery. Given its heterogeneity, better characterization of it might provide crucial insights for clinical practice. This study aimed to analyze the timeline and sequence of events that lead to death after pancreatoduodenectomy to identify possible distinct pathways of mortality.

METHODS

All consecutive pancreatoduodenectomy cases from 2010 to 2020 were retrospectively analyzed. A day-to-day appraisal of the postoperative course of each fatality was performed and visualized graphically. The graphical analysis allowed for pattern identification. The respective predictors were explored through logistic regression.

RESULTS

Out of 2065 pancreatoduodenectomy patients, in-hospital mortality was 3.1%. With graphical analysis, 3 patterns were identified. Pattern A deaths (71.4%, n = 45) occurred after a median of 43 days (14-260), following pancreas-specific complications such as postoperative pancreatic fistula, postpancreatectomy hemorrhage, and delayed gastric emptying. Pattern B deaths (15.9%, n = 10) occurred after a median of 18 days (1-55), succeeding a critical status in the early postoperative course, mainly related to elevated surgical complexity. Patients with pattern C (12.7%) died after a median of 8 days, mostly for unknown cause after an uneventful postoperative course. The predictors of each pattern were distinctive.

CONCLUSION

Mortality after pancreatoduodenectomy occurs through 3 distinct pathways. This knowledge could spawn an additional endpoint of value to clinicians and hospitals, delivering a supplementary tool for comparison between centers and diversified patient populations, and it might facilitate the identification of the best targets for improvement. Further studies are needed to validate this tripartite reclassification.

Living donor liver transplant outcomes during the COVID-19 pandemic: does a decrease in case volume impact the overall outcomes?

Background

High-volume centers (HVCs) are classically associated with better outcomes. During the coronavirus disease 2019 (COVID-19) pandemic, there has been a decrease in the regular liver transplantation (LT) activity at our center. This study analyzed the effect of the decline in LT on posttransplant patient outcomes at our HVC.

Methods

We compared the surgical outcomes of patients who underwent LT during the COVID-19 pandemic lockdown (April 1, 2020 to September 30, 2020) with outcomes in the pre-pandemic calendar year (April 1, 2019 to March 31, 2020).

Results

During the 6 months of pandemic lockdown, 60 patients underwent LT (43 adults and 17 children) while 228 patients underwent LT (178 adults and 50 children) during the pre-pandemic calendar year. Patients in the pandemic group had significantly higher model for end-stage liver disease (MELD) scores (24.39±9.55 vs. 21.14±9.17, P=0.034), Child-Turcotte-Pugh scores (11.46±2.32 vs. 10.25±2.24, P=0.03), and incidence of acute-on-chronic liver failure (30.2% vs. 10.2%, P=0.002). Despite performing LT in sicker patients with COVID-19-related challenges, the 30-day (14% vs. 18.5%, P=0.479), 3-month (16.3% vs. 20.2%, P=0.557), and 6-month mortality rates (23.3% vs. 28.7%, P=0.477) were lower, but not statistically significant when compared to the pre-pandemic cohort.

Conclusions

During the COVID-19 pandemic lockdown the number of LT procedures performed at our HVC declined by half because prevailing conditions allowed LT in very sick patients only. Despite these changes, outcomes were not inferior during the pandemic period compared to the pre-pandemic calendar year. Greater individualization of patient care contributed to non-inferior outcomes in these sick recipients.

Blumgart anastomosis with polyglycolic acid felt reduces the incidence of pancreatic fistula after pancreaticoduodenectomy: A propensity score analysis

Polyglycolic acid (PGA) felt has been used to prevent clinically relevant postoperative pancreatic fistula (CR‐POPF) after pancreaticoduodenectomy (PD). However, there has been no related research on Blumgart anastomosis. Therefore, this study aimed to investigate the practical significance of Blumgart anastomosis with our new method involving PGA felt to prevent CR‐POPF following PD. Data from 133 consecutive patients who underwent Blumgart anastomosis during PD between June 2015 and November 2021 were reviewed. We applied PGA felt to 35 of these patients starting from July 2020. Surgical outcomes were analyzed by propensity score matching. Thirty‐five (35.7%) of the 98 patients in the without‐PGA group were matched with an equal number from the with‐PGA group after adjusting for covariates. CR‐POPF was found in 17 patients (49%) in the without‐PGA group and two patients (6%) in the with‐PGA group (P < .001). The multivariate analysis results indicated that male sex, pancreatic duct size <3 mm, soft pancreatic texture, and nonuse of PGA were independently associated with CR‐POPF after PD. In conclusion, Blumgart anastomosis with our new penetrating method for PGA felt reduces the incidence of CR‐POPF after PD.

Association between hospital volume, processes of care and outcomes after acute ischaemic stroke: a prospective observational study

OBJECTIVES

There is uncertainty with respect to the hospital volume and clinical outcomes for patients with stroke. This study aimed to assess the association between hospital volume, processes of care and outcomes after ischaemic stroke.

DESIGN

A multicentre prospective cohort study.

SETTING

Two hundred and seventeen secondary or tertiary public hospitals from China.

PARTICIPANTS

A total of 17 550 patients within 7 days of acute ischaemic stroke were included.

MAIN OUTCOME MEASURES

The outcomes included all-cause mortality, poor outcome, recurrent stroke, and combined vascular events at 3 months and 1 year. The patients were divided into four groups based on quartiles of the hospital volume. We compared the difference in the process of care across the groups and estimated the effects of hospital volume on mortality, poor outcome, recurrent stroke, and combined vascular events at 3 months and 1 year. Restricted cubic splines were used to illustrate the association between hospital volume and clinical outcomes.

RESULTS

There were no significant differences in the process of care across the four groups. When adjusted for confounders, the effect of hospital volume on mortality, recurrent stroke and combined vascular events was not significant. However, compared with the highest quartile, the patients in the lowest quartile of hospital volume tend to have poor outcome at 1 year (OR=1.29, 95% CI 1.01 to 1.64, p=0.0393). The restricted cubic spline analyses suggested a non-linear relationship between hospital volume and 1-year combined vascular events and poor outcome at 3 months and 1 year.

CONCLUSIONS

We found no significant associations between hospital volume, processes of care at the hospital, and mortality, recurrent stroke, and combined vascular events in patients with ischaemic stroke. However, hospital volume may be associated with poor outcome at 1 year.

Antibiotic resistance patterns of bacterial bile cultures during pancreatic surgery-a single center analysis and systematic review

BACKGROUND

Septic complications after pancreatic surgery are common. However, it remains unclear if and how a shift of the microbiological spectrum affects morbidity. The aim of the present study was to assess the microbiological spectrum and antibiotic resistance patterns and their impact on outcome.

METHODS

We conducted a retrospective study including patients undergoing pancreatic surgery at our center between 2005 and 2018. A systematic literature review and descriptive meta-analysis of the published and original data was performed according to the PRISMA guidelines.

RESULTS

A total of 318 patients were included in the analysis. Patients with biliary drainage had a significantly higher incidence of bacterobilia (93% vs. 25%) and received preoperative antibiotics (46% vs. 12%). The analyzed bile cultures showed no resistance to piperacillin/tazobactam, fluoroquinolones, or carbapenems. Resistance to cefuroxime was seen in 58% of the samples of patients without biliary drainage (NBD) and 93% of the samples of those with drainage (BD). In general, there was no significant difference in overall postoperative morbidity. However, superficial surgical site infections (SSIs) were significantly more common in the BD group. We included a total of six studies and our own data (1627 patients) in the descriptive meta-analysis. The percentage of positive bile cultures ranged from 53 to 81%. In patients with BD, the most frequent microorganisms were Enterococcus spp. (58%), Klebsiella spp. (29%), and E. coli (27%). Almost all studies demonstrated resistance to first- and second-generation cephalosporins and to third- and fourth-generation cephalosporins for patients with BD.

CONCLUSION

A change in perioperative antibiotic strategy according to local resistance patterns, especially after BD, might be useful for patients undergoing pancreatic surgery. Appropriate perioperative antibiotic coverage may help to prevent abdominal infectious complications and especially superficial SSIs.

The impact of upper gastrointestinal surgical volume on short term pancreaticoduodenectomy outcomes for pancreatic adenocarcinoma in the SEER-Medicare population

BACKGROUND

Patients undergoing pancreaticoduodenectomy (PD) at low volume PD hospitals with high volume for other complex operations have comparable outcomes to high volume PD centers. We evaluated the impact of upper gastrointestinal operations (UGI) hospital volume on the outcomes of elderly, high risk patients undergoing PD.

METHODS

Patients >65 years old who underwent PD for pancreatic adenocarcinoma were identified from SEER-Medicare (2008-2015). Four volume cohorts were created using PD tertiles and UGI median: low (1st tertile PD), mixed-low (2nd tertile PD, low UGI), mixed-high (2nd tertile PD, high UGI) and high (3rd tertile PD). Multivariable logistic and negative binomial regression assessed short-term complications.

RESULTS

In total, 2717 patients were identified with a median age of 74.5 years. Patients treated at low, mixed-low and mixed-high volume hospitals, versus high volume, had higher risk of short-term complications, including major complications (low: OR 1.441, 95%CI 1.165-1.783; mixed-low: OR 1.374, 95%CI 1.085-1.740; mixed-high: OR 1.418, 95%CI 1.098-1.832) and 90-day mortality (low: OR 2.16, 95%CI 1.454-3.209; mixed-low: OR 2.068, 95%CI 1.347-3.175; mixed-high: OR 1.96, 95%CI 1.245-3.086).

CONCLUSION

Patients with pancreatic adenocarcinoma who are older and more medically complex benefit from undergoing surgery at high volume PD centers, independent of the operative experience of that center.

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 Effect of Hospital Versus Surgeon Volume on Short-Term Patient Outcomes After Pancreaticoduodenectomy: a SEER-Medicare Analysis

BACKGROUND

The volume-outcome relationship has been well-established for pancreaticoduodenectomy (PD). It remains unclear if this is primarily driven by hospital volume or individual surgeon experience.

OBJECTIVE

This study aimed to determine the relationship of hospital and surgeon volume on short-term outcomes of patients with pancreatic adenocarcinoma undergoing PD.

METHODS

Patients >65 years of age who underwent PD for pancreatic adenocarcinoma were identified from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database (2008-2015). Analyses were stratified by hospital volume and then surgeon volume, creating four volume cohorts: low-low (low hospital, low surgeon), low-high (low hospital, high surgeon), high-low (high hospital, low surgeon), high-high (high hospital, high surgeon). Propensity scores were created for the odds of undergoing surgery with high-volume surgeons. Following matching, multivariable analysis was used to assess the impact of surgeon volume on outcomes within each hospital volume cohort.

RESULTS

In total, 2450 patients were identified: 54.3% were treated at high-volume hospitals (27.0% low-volume surgeons, 73.0% high-volume surgeons) and 45.7% were treated at low-volume hospitals (76.9% low-volume surgeons, 23.1% high-volume surgeons). On matched multivariable analysis, there were no significant differences in the risk of major complications, 90-day mortality, and 30-day readmission based on surgeon volume within the low and high hospital volume cohorts.

CONCLUSION

Compared with surgeon volume, hospital volume is a more significant factor in predicting short-term outcomes after PD. This suggests that a focus on resources and care pathways, in combination with volume metrics, is more likely to achieve high-quality care for patients undergoing PD across all hospitals.