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Augustinus S, Schafrat PJM, Janssen BV, Bonsing BA, Brosens LAA, Busch OR, Crobach S, Doukas M, van Eijck CH, van der Geest LGM, Groot Koerkamp B, de Hingh IHJT, Raicu GM, van Santvoort HC, van Velthuysen ML, Verheij J, Besselink MG, Farina Sarasqueta A. Nationwide Impact of Centralization, Neoadjuvant Therapy, Minimally Invasive Surgery, and Standardized Pathology Reporting on R0 Resection and Overall Survival in Pancreatoduodenectomy for Pancreatic Cancer. Ann Surg Oncol 2023; 30:5051-5060. [PMID: 37210448 PMCID: PMC10319672 DOI: 10.1245/s10434-023-13465-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 03/22/2023] [Indexed: 05/22/2023]
Abstract
BACKGROUND Surgeons aim for R0 resection in patients with pancreatic cancer to improve overall survival. However, it is unclear whether recent changes in pancreatic cancer care such as centralization, increased use of neoadjuvant therapy, minimally invasive surgery, and standardized pathology reporting have influenced R0 resections and whether R0 resection remains associated with overall survival. METHODS This nationwide retrospective cohort study included consecutive patients after pancreatoduodenectomy (PD) for pancreatic cancer from the Netherlands Cancer Registry and the Dutch Nationwide Pathology Database (2009-2019). R0 resection was defined as > 1 mm tumor clearance at the pancreatic, posterior, and vascular resection margins. Completeness of pathology reporting was scored on the basis of six elements: histological diagnosis, tumor origin, radicality, tumor size, extent of invasion, and lymph node examination. RESULTS Among 2955 patients after PD for pancreatic cancer, the R0 resection rate was 49%. The R0 resection rate decreased from 68 to 43% (2009-2019, P < 0.001). The extent of resections in high-volume hospitals, minimally invasive surgery, neoadjuvant therapy, and complete pathology reports all significantly increased over time. Only complete pathology reporting was independently associated with lower R0 rates (OR 0.76, 95% CI 0.69-0.83, P < 0.001). Higher hospital volume, neoadjuvant therapy, and minimally invasive surgery were not associated with R0. R0 resection remained independently associated with improved overall survival (HR 0.72, 95% CI 0.66-0.79, P < 0.001), as well as in the 214 patients after neoadjuvant treatment (HR 0.61, 95% CI 0.42-0.87, P = 0.007). CONCLUSIONS The nationwide rate of R0 resections after PD for pancreatic cancer decreased over time, mostly related to more complete pathology reporting. R0 resection remained associated with overall survival.
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Affiliation(s)
- Simone Augustinus
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
| | - Pascale J M Schafrat
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Boris V Janssen
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Stijn Crobach
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Michail Doukas
- Department of Pathology, Erasmus Medical Center, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Lydia G M van der Geest
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | | | - G Mihaela Raicu
- Department of Pathology, St Antonius Hospital and Pathology DNA, Nieuwegein, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht, Utrecht & St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | | | - Joanne Verheij
- Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
| | - Arantza Farina Sarasqueta
- Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
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Zwart MJW, Nota CLM, de Rooij T, van Hilst J, Te Riele WW, van Santvoort HC, Hagendoorn J, Borei Rinkes IHM, van Dam JL, Latenstein AEJ, Takagi K, Tran KTC, Schreinemakers J, van der Schelling GP, Wijsman JH, Festen S, Daams F, Luyer MD, de Hingh IHJT, Mieog JSD, Bonsing BA, Lips DJ, Hilal MA, Busch OR, Saint-Marc O, Zehl HJ, Zureikat AH, Hogg ME, Molenaar IQ, Besselink MG, Koerkamp BG. Outcomes of a Multicenter Training Program in Robotic Pancreatoduodenectomy (LAELAPS-3). Ann Surg 2022; 276:e886-e895. [PMID: 33534227 DOI: 10.1097/sla.0000000000004783] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess feasibility and safety of a multicenter training program in robotic pancreatoduodenectomy (RPD) adhering to the IDEAL framework for implementation of surgical innovation. BACKGROUND Good results for RPD have been reported from single center studies. However, data on feasibility and safety of implementation through a multicenter training program in RPD are lacking. METHODS A multicenter training program in RPD was designed together with the University of Pittsburgh Medical Center, including an online video bank, robot simulation exercises, biotissue drills, and on-site proctoring. Benchmark patients were based on the criteria of Clavien. Outcomes were collected prospectively (March 2016-October 2019). Cumulative sum analysis of operative time was performed to distinguish the first and second phase of the learning curve. Outcomes were compared between both phases of the learning curve. Trends in nationwide use of robotic and laparoscopic PD were assessed in the Dutch Pancreatic Cancer Audit. RESULTS Overall, 275 RPD procedures were performed in seven centers by 15 trained surgeons. The recent benchmark criteria for low-risk PD were met by 125 (45.5%) patients. The conversion rate was 6.5% (n = 18) and median blood loss 250ml [interquartile range (IQR) 150-500]. The rate of Clavien-Dindo grade ≥III complications was 44.4% (n = 122), postoperative pancreatic fistula (grade B/C) rate 23.6% (n = 65), 90-day complication-related mortality 2.5% (n = 7) and 90-day cancer-related mortality 2.2.% (n = 6). Median postoperative hospital stay was 12 days (IQR 8-20). In the subgroup of patients with pancreatic cancer (n = 80), the major complication rate was 31.3% and POPF rate was 10%. Cumulative sum analysis for operative time found a learning curve inflection point at 22 RPDs (IQR 10-35) with similar rates of Clavien-Dindo grade ≥III complications in the first and second phase (43.4% vs 43.8%, P = 0.956, respectively). During the study period the nationwide use of laparoscopic PD reduced from 15% to 1%, whereas the use of RPD increased from 0% to 25%. CONCLUSIONS This multicenter RPD training program in centers with sufficient surgical volume was found to be feasible without a negative impact of the learning curve on clinical outcomes.
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Affiliation(s)
- Maurice J W Zwart
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Carolijn L M Nota
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Thijs de Rooij
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Jony van Hilst
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
- Department of Surgery, OLVG, Amsterdam, the Netherlands
| | - Wouter W Te Riele
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Jeroen Hagendoorn
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Inne H M Borei Rinkes
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Jacob L van Dam
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Anouk E J Latenstein
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Kosei Takagi
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Khé T C Tran
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | | | - Jan H Wijsman
- Department of Surgery, Amphia Ziekenhuis, Breda, the Netherlands
| | | | - Freek Daams
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - Misha D Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Jan S D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Mohammed Abu Hilal
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, UK
- Department of Surgery, Istituto Fondazione Poliambulanza, Brescia, Italy
| | - Olivier R Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Olivier Saint-Marc
- Department of Surgery, Centre Hospitalier Regional Orleans, Orleans, France
| | - Herbert J Zehl
- Department of Surgery, University of Texas, Southwestern, Dallas, Texas
| | - Amer H Zureikat
- Department of Surgery, Hillman Cancer Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Melissa E Hogg
- Department of Surgery, Northshore University HealthSystem, Chicago, Illinois
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center and St Antonius Hospital Nieuwegein, Utrecht University, Utrecht, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
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Ignatavicius P, Oberkofler CE, Jonas JP, Mullhaupt B, Clavien PA. The essential requirements for an HPB centre to deliver high-quality outcomes. J Hepatol 2022; 77:837-848. [PMID: 35577030 DOI: 10.1016/j.jhep.2022.04.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 04/12/2022] [Accepted: 04/27/2022] [Indexed: 12/04/2022]
Abstract
The concept of a centre approach to the treatment of patients with complex disorders, such as those with hepato-pancreato-biliary (HPB) diseases, is widely applied, although what is needed for an HPB centre to achieve high-quality outcomes remains unclear. We therefore conducted a literature review, which highlighted the paucity of information linking centre structure or process to outcome data outside of caseloads, specialisation, and quality of training. We then conducted an international survey among the largest 107 HPB centres with experts in HPB surgery and found that most responders work in 'virtual' HPB centres without dedicated space, assigned beds, nor personal. We finally analysed our experience with the Swiss HPB centre, previously reported in this journal 15 years ago, disclosing that budget priorities set by the hospital administration may prevent the development of a fully integrated centre, for example through inconsistent assignment of the centre's beds to HBP patients or removal of dedicated intermediate care beds. We propose criteria for essential requirements for an HPB centre to deliver high-quality outcomes, with the concept of "centre of reference" limited to actual, as opposed to virtual, centres.
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Affiliation(s)
- Povilas Ignatavicius
- Swiss Hepato-Pancreato-Biliary (HPB) Center Zurich, Zurich, Switzerland; Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Christian E Oberkofler
- Swiss Hepato-Pancreato-Biliary (HPB) Center Zurich, Zurich, Switzerland; Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Jan Philipp Jonas
- Swiss Hepato-Pancreato-Biliary (HPB) Center Zurich, Zurich, Switzerland; Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Beat Mullhaupt
- Swiss Hepato-Pancreato-Biliary (HPB) Center Zurich, Zurich, Switzerland; Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Pierre-Alain Clavien
- Swiss Hepato-Pancreato-Biliary (HPB) Center Zurich, Zurich, Switzerland; Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland.
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Johansen K, Lindhoff Larsson A, Gasslander T, Lundgren L, Hasselgren K, Sandström P, Borch K, Björnsson B. Complications and chemotherapy have little impact on postoperative quality of life after pancreaticoduodenectomy - a cohort study. HPB (Oxford) 2022; 24:1464-73. [PMID: 35410782 DOI: 10.1016/j.hpb.2022.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 01/21/2022] [Accepted: 02/28/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND With the poor prognosis of pancreatic cancer and the high rate of postoperative complications after pancreaticoduodenectomy, it is important to evaluate how the operation affects patients' quality of life. METHODS This single-centre study included all patients undergoing pancreaticoduodenectomy from 2006 to 2016. Quality of life was measured with two questionnaires preoperatively, and at 6 and 12 months postoperatively. Comparisons between groups were made using a linear mixed models analysis. RESULTS Of 279 patients planned for pancreaticoduodenectomy, 245 underwent the operation. The postoperative response rates were all 80% or more. Differences were found in one domain between the early and late time periods and three domains between patients receiving and not receiving adjuvant chemotherapy. No significant differences were found between patients with and without severe postoperative complications. However, the demographic variables of age group, sex, preoperative diabetes and smoking all exerted a significant impact on postoperative quality of life. CONCLUSION While little or no impact was shown for the factors of postoperative complications, time period and adjuvant chemotherapy, demographic data, such as age, sex, preoperative diabetes and smoking, had considerable impacts on postoperative quality of life after pancreaticoduodenectomy.
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Thomas AS, Sharma RK, Kwon W, Sugahara KN, Chabot JA, Schrope BA, Kluger MD. Socioeconomic Predictors of Access to Care for Patients with Operatively Managed Pancreatic Cancer in New York State. J Gastrointest Surg 2022; 26:1647-1662. [PMID: 35501551 DOI: 10.1007/s11605-022-05320-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 03/26/2022] [Indexed: 01/31/2023]
Abstract
PURPOSE We evaluated how race and socioeconomic factors impact access to high-volume surgical centers, treatment initiation, and postoperative care for pancreatic cancer in a state with robust safety net insurance coverage and healthcare infrastructure. METHODS The New York Statewide Planning and Research Cooperative System was analyzed. Patients with pancreatic cancer resected from 2007 to 2017 were identified by ICD and CPT codes. Primary outcomes included surgery at low-volume facilities (< 20 pancreatectomies/year), time to therapy initiation, and time to postoperative surveillance imaging (within 60-180 days after surgery). RESULTS In total, 3312 patients underwent pancreatectomy across 124 facilities. Median age was 67 years (IQR 59, 75) and 55% of patients were male. Most (72.7%) had surgery at high-volume centers. On multivariable analysis, odds ratios for surgery at low-volume centers were increased for Black race (2.21 (95% CI 1.69-2.88)), Asian race (1.64 (95% CI 1.09-2.43)), Hispanic ethnicity (1.68 (95% CI 1.24-2.28)), Medicaid insurance (2.52 (95% CI 1.79-3.56)), no insurance (2.24 (95% CI 1.38-3.61)), lowest income quartile (3.31 (95% CI 2.14-5.32)), and rural zip code (2.49 (95% CI 1.69-3.65)). Patients treated at low-volume centers waited longer to initiate treatment (hazard ratio (HR) 0.91 (95% CI 0.81-1.01)). Black patients underwent the least surveillance imaging (50.4%; p < 0.0001), while Asian (HR 2.04, 95% CI 1.40-2.98)) and Hispanic patients (HR 1.36 (95% CI 1.00-1.84)) were more likely to have surveillance imaging. CONCLUSIONS Race independently affected access to high-volume facilities and surveillance imaging. When considered in light of other accumulating evidence, future efforts might investigate the perceptions and logistical considerations noted by providers and patients alike to identify the etiology of these disparities and then institute corrective measures.
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Affiliation(s)
- Alexander S Thomas
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center: Herbert Irving Pavilion, 177 Fort Washington Ave, New York, NY, 10032, USA.
| | - Rahul K Sharma
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Wooil Kwon
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center: Herbert Irving Pavilion, 177 Fort Washington Ave, New York, NY, 10032, USA
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Kazuki N Sugahara
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center: Herbert Irving Pavilion, 177 Fort Washington Ave, New York, NY, 10032, USA
| | - John A Chabot
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center: Herbert Irving Pavilion, 177 Fort Washington Ave, New York, NY, 10032, USA
| | - Beth A Schrope
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center: Herbert Irving Pavilion, 177 Fort Washington Ave, New York, NY, 10032, USA
| | - Michael D Kluger
- Division of GI/Endocrine Surgery, Department of Surgery, Columbia University Irving Medical Center: Herbert Irving Pavilion, 177 Fort Washington Ave, New York, NY, 10032, USA
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Ratnayake B, Pendharkar SA, Connor S, Koea J, Sarfati D, Dennett E, Pandanaboyana S, Windsor JA. Patient volume and clinical outcome after pancreatic cancer resection: A contemporary systematic review and meta-analysis. Surgery 2022; 172:273-283. [PMID: 35034796 DOI: 10.1016/j.surg.2021.11.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 11/02/2021] [Accepted: 11/29/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Pancreatic cancer remains a highly fatal disease with a 5-year overall survival of less than 10%. In seeking to improve clinical outcomes, there is ongoing debate about the weight that should be given to patient volume in centralization models. The aim of this systematic review is to examine the relationship between patient volume and clinical outcome after pancreatic resection for cancer in the contemporary literature. METHODS The Google Scholar, PubMed, and Cochrane Library databases were systematically searched from February 2015 until June 2021 for articles reporting patient volume and outcomes after pancreatic cancer resection. RESULTS There were 46 eligible studies over a 6-year period comprising 526,344 patients. The median defined annual patient volume thresholds varied: low-volume 0 (range 0-9), medium-volume 9 (range 3-29), high-volume 19 (range 9-97), and very-high-volume 28 (range 17-60) patients. The latter 2 were associated with a significantly lower 30-day mortality (P < .001), 90-day mortality (P < .001), overall postoperative morbidity (P = .005), failure to rescue rate (P = .006), and R0 resection rate (P = .008) compared with very-low/low-volume hospitals. Centralization was associated with lower 30-day mortality in 3 out of 5 studies, while postoperative morbidity was similar in 4 out of 4 studies. Median survival was longer in patients traveling greater distance for pancreatic resection in 2 out of 3 studies. Median and 5-year survival did not differ between urban and rural settings. CONCLUSION The contemporary literature confirms a strong relationship between patient volume and clinical outcome for pancreatic cancer resection despite expected bias toward more complex surgery in high-volume centers. These outcomes include lower mortality, morbidity, failure-to-rescue, and positive resection margin rates.
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Affiliation(s)
- Bathiya Ratnayake
- Surgical and Translational Research Centre, Faculty of Medical and Health Science, University of Auckland, New Zealand; HBP/Upper GI Unit, Auckland City Hospital, Auckland, New Zealand. https://twitter.com/ProfJohnWindsor
| | - Sayali A Pendharkar
- Surgical and Translational Research Centre, Faculty of Medical and Health Science, University of Auckland, New Zealand
| | - Saxon Connor
- Department of Surgery, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Jonathan Koea
- Upper GI Unit, Northshore Hospital, Waitemata District Health Board, Auckland, New Zealand
| | - Diana Sarfati
- Department of Public Health, University of Otago, Dunedin, New Zealand; Cancer Control Agency, Te Aho O Te Kahu, Ministry of Health, New Zealand
| | - Elizabeth Dennett
- Cancer Control Agency, Te Aho O Te Kahu, Ministry of Health, New Zealand
| | - Sanjay Pandanaboyana
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK; Population Health Sciences Institute, Newcastle University, Newcastle, UK
| | - John A Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Science, University of Auckland, New Zealand; HBP/Upper GI Unit, Auckland City Hospital, Auckland, New Zealand.
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Huhta H, Nortunen M, Meriläinen S, Helminen O, Kauppila JH. Hospital volume and outcomes of pancreatic cancer: a Finnish population-based nationwide study. HPB (Oxford) 2022; 24:841-847. [PMID: 34824013 DOI: 10.1016/j.hpb.2021.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 10/13/2021] [Accepted: 10/22/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pancreatic cancer surgery is associated with high incidence of short- and long-term morbidity and mortality. The aim of this study was to assess whether the hospital volume of pancreatic surgery is associated with better survival in a population-based setting. METHODS All patients who underwent pancreatic resection for cancer in Finland during 1997-2016 were identified from nationwide registries. The follow-up ended on 31 December 2019. Patients were divided into quintiles based on annual hospital volume (4-year moving average): ≤4, 5-9, 10-18, 19-36 and ≥ 37 resections per year. Cox regression provided hazard ratios (HR) and 95% confidence intervals (CI), adjusted for age, sex, comorbidity and year of surgery. RESULTS The number of diagnosed pancreatic cancers was 22,724. Of these, 1514 underwent pancreatic surgery due to pancreatic ductal adenocarcinoma. The 5-year survival ranged from 12% to 28%, increasing with higher annual operative volume. Adjusted 5-year mortality was higher in all other quintiles compared to the highest annual volume quintile (HR 1.43, 95% CI 1.16-1.75). Thirty and 90-day mortality were higher in the three lowest volume, compared to the highest quintile. CONCLUSION Higher annual hospital volume of pancreatic surgery for pancreatic ductal adenocarcinoma is associated with improved short- and long-term survival.
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Affiliation(s)
- Heikki Huhta
- Surgery and Intensive Care Research Unit, Oulu University Hospital, Oulu, Finland.
| | - Minna Nortunen
- Surgery and Intensive Care Research Unit, Oulu University Hospital, Oulu, Finland
| | - Sanna Meriläinen
- Surgery and Intensive Care Research Unit, Oulu University Hospital, Oulu, Finland
| | - Olli Helminen
- Surgery and Intensive Care Research Unit, Oulu University Hospital, Oulu, Finland
| | - Joonas H Kauppila
- Surgery and Intensive Care Research Unit, Oulu University Hospital, Oulu, Finland; Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden
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Mitsakos AT, Vohra NA, Fitzgerald TL, Buccini P, Parikh AA, Snyder RA, Zervos EE. Improvement in Surgical Quality Following Pancreaticoduodenectomy With Increasing Case Volume in a Rural Hospital. Am Surg 2021; 88:746-751. [PMID: 34792413 DOI: 10.1177/00031348211050808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The literature is replete with studies that define the nexus of quantity and quality in complex surgical operations. These observations have heralded a call for centralization of care to high-volume centers. The purpose of this study was to chronicle improvements in quality associated with pancreaticoduodenectomy (PD) as a rural hospital matures from a low- to very high-volume center. METHODS A retrospective review of a prospective pancreatic surgery database was undertaken from July 2007 to June 2020. Annual periods were characterized as low (≤12/year), high (13-29/year), and very high volume (≥30/year). Data for the following quality benchmarks were aggregated and compared: length of stay (LOS), 30-day readmissions, 30-day mortality, and 1- and 3-year survival. A subgroup analysis was undertaken in those patients undergoing PD for adenocarcinoma detailing margin status and number of lymph nodes harvested. Outcomes were compared using the Fisher's exact and Student's t-test. RESULTS 375 PD were completed over the 13-year period; 62.1% were undertaken for ductal adenocarcinoma. There was a significant decrease in LOS and 30-day readmissions as the institution matured toward very high volume. There were no significant differences in 30-day mortality, 1- and 3-year survival, or margin negativity rates associated with volume. Extent of lymph node harvest significantly improved as institutional experience increased. DISCUSSION Our pancreatic surgery program matured rapidly from low to very high volume with institutional commitment and dedicated resources. As the institution matured, operational efficiencies and surgical quality improved. Not unexpectedly, biology trumped volume as reflected in 1- and 3-year survival rates.
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Affiliation(s)
- Anastasios T Mitsakos
- Department of Surgery, Division of Surgical Oncology, 12278Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Nasreen A Vohra
- Department of Surgery, Division of Surgical Oncology, 12278Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Timothy L Fitzgerald
- Department of Surgery, Division of Surgical Oncology, 92602Maine Medical Center, Portland, ME, USA
| | - Peter Buccini
- Department of Surgery, Division of Surgical Oncology, 12278Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Alexander A Parikh
- Department of Surgery, Division of Surgical Oncology, 12278Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Rebecca A Snyder
- Department of Surgery, Division of Surgical Oncology, 12278Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Emmanuel E Zervos
- Department of Surgery, Division of Surgical Oncology, 12278Brody School of Medicine at East Carolina University, Greenville, NC, USA
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Wakiya T, Ishido K, Kimura N, Nagase H, Kubota S, Fujita H, Hagiwara Y, Kanda T, Matsuzaka M, Sasaki Y, Hakamada K. Prediction of massive bleeding in pancreatic surgery based on preoperative patient characteristics using a decision tree. PLoS One 2021; 16:e0259682. [PMID: 34752505 PMCID: PMC8577735 DOI: 10.1371/journal.pone.0259682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 10/24/2021] [Indexed: 12/24/2022] Open
Abstract
Massive intraoperative blood loss (IBL) negatively influence outcomes after surgery for pancreatic ductal adenocarcinoma (PDAC). However, few data or predictive models are available for the identification of patients with a high risk for massive IBL. This study aimed to build a model for massive IBL prediction using a decision tree algorithm, which is one machine learning method. One hundred and seventy-five patients undergoing curative surgery for resectable PDAC at our facility between January 2007 and October 2020 were allocated to training (n = 128) and testing (n = 47) sets. Using the preoperatively available data of the patients (34 variables), we built a decision tree classification algorithm. Of the 175 patients, massive IBL occurred in 88 patients (50.3%). Binary logistic regression analysis indicated that alanine aminotransferase and distal pancreatectomy were significant predictors of massive IBL occurrence with an overall correct prediction rate of 70.3%. Decision tree analysis automatically selected 14 predictive variables. The best predictor was the surgical procedure. Though massive IBL was not common, the outcome of patients with distal pancreatectomy was secondarily split by glutamyl transpeptidase. Among patients who underwent PD (n = 83), diabetes mellitus (DM) was selected as the variable in the second split. Of the 21 patients with DM, massive IBL occurred in 85.7%. Decision tree sensitivity was 98.5% in the training data set and 100% in the testing data set. Our findings suggested that a decision tree can provide a new potential approach to predict massive IBL in surgery for resectable PDAC.
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Affiliation(s)
- Taiichi Wakiya
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Keinosuke Ishido
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Norihisa Kimura
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Hayato Nagase
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Shunsuke Kubota
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Hiroaki Fujita
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Yusuke Hagiwara
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Taishu Kanda
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Masashi Matsuzaka
- Department of Medical Informatics, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Yoshihiro Sasaki
- Department of Medical Informatics, Hirosaki University Hospital, Hirosaki, Aomori, Japan
| | - Kenichi Hakamada
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
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10
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Kanda T, Wakiya T, Ishido K, Kimura N, Nagase H, Kubota S, Fujita H, Hagiwara Y, Hakamada K. Intraoperative Allogeneic Red Blood Cell Transfusion Negatively Influences Prognosis After Radical Surgery for Pancreatic Cancer: A Propensity Score Matching Analysis. Pancreas 2021; 50:1314-1325. [PMID: 34860818 DOI: 10.1097/mpa.0000000000001913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE We aimed to investigate the real impact of allogeneic red blood cell transfusion (ABT) on postoperative outcomes in resectable pancreatic ductal adenocarcinoma (PDAC) patients. METHODS Of 128 patients undergoing resectable PDAC surgery at our facility, 24 (18.8%) received ABT. Recurrence-free survival (RFS) and disease-specific survival (DSS), before and after propensity score matching (PSM), were compared among patients who did and did not receive ABT. RESULTS In the entire cohort, ABT was significantly associated with decreased RFS (P = 0.002) and DSS (P = 0.014) before PSM. Cox regression analysis identified ABT (risk ratio, 1.884; 95% confidence interval, 1.015-3.497; P = 0.045) as an independent prognostic factor for RFS. Univariate and multivariate analysis identified preoperative hemoglobin value, preoperative total bilirubin value, and intraoperative blood loss as significant independent risk factors for ABT. Using these 3 variables, PSM analysis created 16 pairs of patients. After PSM, the ABT group had significantly poorer RFS rates than the non-ABT group (median, 9.8 vs 15.8 months, P = 0.022). Similar tendencies were found in DSS rates (median, 19.4 vs 40.0 months, P = 0.071). CONCLUSIONS This study revealed certain negative effects of intraoperative ABT on postoperative survival outcomes in patients with resectable PDAC.
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Affiliation(s)
- Taishu Kanda
- From the Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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11
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de la Fouchardière C, Adham M, Marion-Audibert AM, Duclos A, Darcha C, Berthelet O, Hervieu V, Artru P, Labrosse H, Fayet Y, Ferroud-Plattet B, Aublet-Cuvellier B, Chambon G, Baconnier M, Rebischung C, Farsi F, Ray-Coquard I, Mastier C, Ternamian PJ, Williet N, Buc E, Walter T, Herr AL. Management of Patients with Pancreatic Ductal Adenocarcinoma in the Real-Life Setting: Lessons from the French National Hospital Database. Cancers (Basel) 2021; 13:3515. [PMID: 34298729 DOI: 10.3390/cancers13143515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 07/09/2021] [Accepted: 07/10/2021] [Indexed: 02/06/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) remains a major public health challenge, and faces disparities and delays in the diagnosis and access to care. Our purposes were to describe the medical path of PDAC patients in the real-life setting and evaluate the overall survival at 1 year. We used the national hospital discharge summaries database system to analyze the management of patients with newly diagnosed PDAC over the year 2016 in Auvergne-Rhône-Alpes region (AuRA) (France). A total of 1872 patients met inclusion criteria corresponding to an incidence of 22.6 per 100,000 person-year. Within the follow-up period, 353 (18.9%) were operated with a curative intent, 743 (39.7%) underwent chemo- and/or radiotherapy, and 776 (41.4%) did not receive any of these treatments. Less than half of patients were operated in a high-volume center, defined by more than 20 PDAC resections performed annually, mainly university hospitals. The 1-year survival rate was 47% in the overall population. This study highlights that a significant number of patients with PDAC are still operated in low-volume centers or do not receive any specific oncological treatment. A detailed analysis of the medical pathways is necessary in order to identify the medical and territorial determinants and their impact on the patient's outcome.
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12
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Johansen K, Lundgren L, Gasslander T, Hasselgren K, Sandström P, Björnsson B. High resection rate improves overall survival in elderly patients with pancreatic head cancer – A cohort study. International Journal of Surgery Open 2021. [DOI: 10.1016/j.ijso.2021.100362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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13
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van der Heijde N, Vissers FL, Boggi U, Dokmak S, Edwin B, Hackert T, Khatkov IE, Keck T, Besselink MG, Abu Hilal M. Designing the European registry on minimally invasive pancreatic surgery: a pan-European survey. HPB (Oxford) 2021; 23:566-574. [PMID: 32933843 DOI: 10.1016/j.hpb.2020.08.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 07/08/2020] [Accepted: 08/21/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The recent Miami international evidence-based guidelines on minimally invasive pancreatic surgery (MIPS) advise all centers that perform MIPS to participate in multicenter registries to safeguard optimal outcomes and patient safety. During the design phase of a pan-European registry on MIPS, the European consortium of Minimally Invasive Pancreatic Surgery (E-MIPS) sought input from European HPB surgeons. METHODS An anonymous online questionnaire with 23 questions on MIPS practice was sent to all member centers of the European-African Hepato-Pancreato-Biliary Association (E-AHPBA) and E-MIPS. RESULTS Completed questionnaires were obtained from 98 centers in 23 countries, of which 75 (76.5%) were academic centers. Centers had a median annual pancreatoduodenectomy volume of 45. The most-performed MIPS procedure was laparoscopic distal pancreatectomy (93.9% of centers). Minimally invasive pancreatoduodenectomy was performed in 49% of all centers. Some 25 centers already participated in an ongoing national registry, and were willing to share their data with the European registry on MIPS. The most mentioned (45.4%) maximum time for processing one patient's data into the registry was 10-15 min. CONCLUSION This European survey showed considerable support for the European registry on MIPS.
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Affiliation(s)
- Nicky van der Heijde
- Department of Surgery, Southampton University Hospital, Southampton, United Kingdom; Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Frederique L Vissers
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Pisa, Italy
| | - Safi Dokmak
- Department of Surgery, Beaujon Hospital, Clichy, France
| | - Bjørn Edwin
- The Intervention Centre and Department of HPB Surgery, Oslo University Hospital and Institute for Clinical Medicine, Oslo, Norway
| | - Thilo Hackert
- Department of Surgery, University of Heidelberg, Heidelberg, Germany
| | - Igor E Khatkov
- Department of Surgery, Moscow Clinical Scientific Center, Moscow, Russia
| | - Tobias Keck
- Clinic for Surgery, University of Schleswig-Holstein Campus Lübeck, Lübeck, Germany
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands.
| | - Mohammed Abu Hilal
- Department of Surgery, Southampton University Hospital, Southampton, United Kingdom; Department of Surgery, Instituto Fondazione Poliambulanza, Brescia, Italy.
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14
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Marchese U, Fuks D, Truant S, El Amrani M. Comment on: Failure to rescue in patients with distal pancreatectomy: a nationwide analysis of 10,632 patients. Hepatobiliary Surg Nutr 2021; 10:229-231. [PMID: 33898563 DOI: 10.21037/hbsn-21-105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Ugo Marchese
- Department of Digestive, Hepatobiliary and Endocrine Surgery, Paris University, Cochin Hospital, AP-HP, 75014 Paris, France
| | - David Fuks
- Department of Digestive, Hepatobiliary and Endocrine Surgery, Paris University, Cochin Hospital, AP-HP, 75014 Paris, France
| | - Stephanie Truant
- Department of Digestive Surgery and Transplantation, Lille University, CHRU de Lille, Lille, France
| | - Mehdi El Amrani
- Department of Digestive Surgery and Transplantation, Lille University, CHRU de Lille, Lille, France
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15
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Fisher AV, Ma Y, Wang X, Campbell-Flohr SA, Rathouz PJ, Ronnekleiv-Kelly SM, Abbott DE, Weber SM. National Trends in Centralization of Surgical Care and Multimodality Therapy for Pancreatic Adenocarcinoma. J Gastrointest Surg 2020; 24:2021-9. [PMID: 31420860 DOI: 10.1007/s11605-019-04361-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 08/05/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Studies have demonstrated that multimodality therapy and surgery at high volume centers are associated with a longer survival. However, it is unknown if these data have translated into national changes in care delivery. METHODS Patients with stages I-III pancreatic adenocarcinomas who underwent resections between 2004 and 2010 were identified from the National Cancer Data Base. The primary outcome was a 3-year overall survival. Temporal trends in survival outcomes and treatment variables were measured. A mediation analysis using the Lin method was used to discern the relative contribution of changes in treatment variables towards improvements in survival over time. RESULTS A total of 22,196 patients were identified. Between 2004 and 2010, a 90-day peri-operative mortality remained unchanged (8.5 % to 8.4 %, p = 0.488), 3-year overall survival improved from 26 to 30% (p < 0.001), use of adjuvant/neoadjuvant chemotherapy increased (51 % to 61 %, p < 0.001), and more cases shifted to high volume centers (46 % at institutions performing > 10 cases/year in 2004 vs. 65 % in 2010, p < 0.001). On multivariable analysis, 32 % of the improvement in survival over time was attributable to receipt of chemotherapy, while 12 % was due to the shift of patients towards high volume centers (p < 0.001). CONCLUSIONS Over the period from 2004 to 2010, a 3-year survival increased for patients undergoing resection for pancreatic cancer. This survival improvement can be partially attributed to the increasing utilization of chemotherapy and centralization of surgical care at high volume centers. A continued emphasis on these factors will likely result in further prolongation of a survival following resection.
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16
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Hansen MFC, Storkholm JH, Hansen CP. The results of pancreatic operations after the implementation of multidisciplinary team conference (MDT): A quality improvement study. Int J Surg 2020; 77:105-10. [PMID: 32234347 DOI: 10.1016/j.ijsu.2020.03.045] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 03/01/2020] [Accepted: 03/19/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Centralization has improved the outcome of complex operations including cancer surgery. Moreover, the implementation of multidisciplinary team conferences (MDT) has ameliorated the decision making, but the impact on patient outcome is controversial. The aim of the study was to investigate the outcome of pancreatic surgery in the setting of centralization and upfront multidisciplinary decision making. METHOD The decisions of MDT from 2010 to 2016 and the outcome of operations were compared with operations from 2003 to 2009 before centralization of pancreatic surgery and implementation of MDT. Data were drawn from the department's database and from hospital's electronic patient files. RESULTS From 2010 to 2016, 7.015 patients were evaluated at the MDT. In 72.6% of patients a treatment plan followed the first evaluation, the referral diagnosis was changed in 12.4% of cases. Of 3.362 solid neoplasms, 1.680 (50.0%) were evaluated as resectable and 1.080 (32.1%) patients were operated. The annual resection rate of operated patients was78.3%-88.5% (median 80.0%) compared to 21.4% to 80.% (median 68.6%, p = 0.0001) from 2003 to 2009 with 279 operated patients. The post-operative 30 - and 90-days mortality from 2003 to 2009 and 2010 to 2016 was 3.4% vs. 1.8% (NS) and 5.0% vs 3.6% (NS). In the same periods explorative laparotomies and palliative resections decreased from 18.3% to 3.6% (p = 0.0001) and 18.6%-10.2% (p = 0.0002). The median survival of radically resected pancreatic adenocarcinoma (PAC) from 2003 to 2009 and from 2010 to 2016 was 20.2 and 21.9 months, respectively (p = 0.687). CONCLUSION The MDT increased patient flow, improved quality of decision-making and offered more patients surgical treatment without increasing morbidity or mortality. But an impact on the long-term survival of patients with PAC was not found.
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Abstract
Background and Aims: The effect of operation volume on the outcomes of pancreatic surgery has been a subject of research since the 1990s. In several countries around the world, this has led to the centralization of pancreatic surgery. However, controversy persists as to the benefits of centralization and what the optimal operation volume for pancreatic surgery actually is. This review summarizes the data on the effect of centralization on mortality, complications, hospital facilities used, and costs regarding pancreatic surgery. Materials and Methods: A systematic librarian-assisted search was performed in PubMed covering the years from August 1999 to August 2019. All studies comparing results of open pancreatic resections from high- and low-volume centers were included. In total 44, published articles were analyzed. Results: Studies used a variety of different criteria for high-volume and low-volume centers, which hampers the evaluating of the effect of operation volume. However, mortality in high-volume centers is consistently reported to be lower than in low-volume centers. In addition, failure to rescue critically ill patients is more common in low-volume centers. Cost-effectiveness has also been evaluated in the literature. Length of hospital stay in particular has been reported to be shorter in high-volume centers than in low-volume centers. Conclusion: The effect of centralization on the outcomes of pancreatic surgery has been under active research and the beneficial effect of it is associated especially with better short-term prognosis after surgery.
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Affiliation(s)
- R. Ahola
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - J. Sand
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
- Tampere University Hospital, Tampere, Finland
| | - J. Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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18
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Roussel E, Clément G, Lenne X, Pruvot FR, Schwarz L, Theis D, Truant S, El Amrani M. Is Centralization Needed for Patients Undergoing Distal Pancreatectomy?: A Nationwide Study of 3314 Patients. Pancreas 2019; 48:1188-94. [PMID: 31593018 DOI: 10.1097/MPA.0000000000001410] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The centralization of complex surgical procedures is associated with better postoperative outcomes. However, little is known about the impact of hospital volume on the outcome after distal pancreatectomy. METHODS Using the French national hospital discharge database, we identified all patients having undergone distal pancreatectomy in France between 2012 and 2015. A spline model was applied to determine the caseload cut-off in annual distal pancreatectomy that influenced 90-day postoperative mortality. RESULTS A total of 3314 patients were identified. Use of a spline model did not reveal a cut-off in the annual distal pancreatectomy caseload. By taking the median number of distal pancreatectomy (n = 5) and the third quartile (n = 15), we stratified centers into low, intermediate, and high hospital volume groups. The overall postoperative mortality rate was 3.0% and did not differ significantly between these groups. In a multivariable analysis, age, Charlson comorbidity score, septic complications, hemorrhage, shock, and reoperation were independently associated with a greater overall risk of death. However, hospital volume had no impact on mortality after distal pancreatectomy (odds ratio, 0.954; 95% confidence interval, 0.552-1.651, P = 0.867). CONCLUSIONS Hospital volume does not seem to influence mortality after distal pancreatectomy in France, and centralization may not necessarily improve outcomes.
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19
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Tingstedt B, Andersson B, Jönsson C, Formichov V, Bratlie SO, Öhman M, Karlsson BM, Ansorge C, Segersvärd R, Gasslander T. First results from the Swedish National Pancreatic and Periampullary Cancer Registry. HPB (Oxford) 2019; 21:34-42. [PMID: 30097413 DOI: 10.1016/j.hpb.2018.06.1811] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 05/21/2018] [Accepted: 06/24/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Despite improvements in therapy regimens over the past decades, overall survival rates for pancreatic and periampullary cancer are poor. Specific cancer registries are set up in various nations to regional differences and to enable larger prospective trials. The aim of this study was to describe the Swedish register, including possibilities to improve diagnostic work-ups, treatment, and follow-up by means of the register. METHODS Since 2010, all patients with pancreatic and periampullary cancer (including also patients who have undergone pancreatic surgery due to premalignant or benign lesions) have been registered in the Swedish National Periampullary and Pancreatic Cancer registry. RESULTS In total 9887 patients are listed in the registry; 8207 of those have malignant periampullary cancer. Approximately one-third (3282 patients) have had resections performed, including benign/premalignant resections. 30-day and 90-day mortality after pancreatoduodenectomy is 1.5% and 3.5%, respectively. The overall 3-year survival for resected pancreatic ductal adenocarcinoma is 35%. Regional variations decreased over the studied period, but still exist. CONCLUSION Results from the Swedish National Registry are satisfactory and comparable to international standards. Trends over time show increasing resection rates and some improved results. Better collaboration and openness within pancreatic surgeons is an important side effect.
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Affiliation(s)
- Bobby Tingstedt
- Department of Surgery, Skåne University Hospital, Lund, Sweden.
| | - Bodil Andersson
- Department of Surgery, Skåne University Hospital, Lund, Sweden
| | - Claes Jönsson
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Svein-Olav Bratlie
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mikael Öhman
- Departments of Surgical and Perioperative Sciences, Umeå University Hospital, Sweden
| | | | - Christophe Ansorge
- Department of Surgical Gastroenterology, Karolinska University Hospital, Stockholm, Sweden
| | - Ralf Segersvärd
- Department of Surgical Gastroenterology, Karolinska University Hospital, Stockholm, Sweden
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20
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Huang L, Jansen L, Balavarca Y, Molina-Montes E, Babaei M, van der Geest L, Lemmens V, Van Eycken L, De Schutter H, Johannesen TB, Fristrup CW, Mortensen MB, Primic-Žakelj M, Zadnik V, Becker N, Hackert T, Mägi M, Cassetti T, Sassatelli R, Grützmann R, Merkel S, Gonçalves AF, Bento MJ, Hegyi P, Lakatos G, Szentesi A, Moreau M, van de Velde T, Broeks A, Sant M, Minicozzi P, Mazzaferro V, Real FX, Carrato A, Molero X, Besselink MG, Malats N, Büchler MW, Schrotz-King P, Brenner H. Resection of pancreatic cancer in Europe and USA: an international large-scale study highlighting large variations. Gut 2019; 68:130-139. [PMID: 29158237 DOI: 10.1136/gutjnl-2017-314828] [Citation(s) in RCA: 114] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 10/24/2017] [Accepted: 11/11/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Resection can potentially cure resectable pancreatic cancer (PaC) and significantly prolong survival in some patients. This large-scale international study aimed to investigate variations in resection for PaC in Europe and USA and determinants for its utilisation. DESIGN Data from six European population-based cancer registries and the US Surveillance, Epidemiology, and End Results Program database during 2003-2016 were analysed. Age-standardised resection rates for overall and stage I-II PaCs were computed. Associations between resection and demographic and clinical parameters were assessed using multivariable logistic regression models. RESULTS A total of 153 698 records were analysed. In population-based registries in 2012-2014, resection rates ranged from 13.2% (Estonia) to 21.2% (Slovenia) overall and from 34.8% (Norway) to 68.7% (Denmark) for stage I-II tumours, with great international variations. During 2003-2014, resection rates only increased in USA, the Netherlands and Denmark. Resection was significantly less frequently performed with more advanced tumour stage (ORs for stage III and IV versus stage I-II tumours: 0.05-0.18 and 0.01-0.06 across countries) and increasing age (ORs for patients 70-79 and ≥80 versus those <60 years: 0.37-0.63 and 0.03-0.16 across countries). Patients with advanced-stage tumours (stage III-IV: 63.8%-81.2%) and at older ages (≥70 years: 52.6%-59.5%) receiving less frequently resection comprised the majority of diagnosed cases. Patient performance status, tumour location and size were also associated with resection application. CONCLUSION Rates of PaC resection remain low in Europe and USA with great international variations. Further studies are warranted to explore reasons for these variations.
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Affiliation(s)
- Lei Huang
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Lina Jansen
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany.,German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Yesilda Balavarca
- Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Esther Molina-Montes
- Geneticand Molecular Epidemiology Group, Spanish National Cancer Research Centre (CNIO), CIBERONC, ISCIII, Madrid, Spain
| | - Masoud Babaei
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Lydia van der Geest
- Netherlands Cancer Registry (NCR), Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, Netherlands
| | - Valery Lemmens
- Netherlands Cancer Registry (NCR), Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, Netherlands
| | | | | | - Tom B Johannesen
- Registry Department, The Cancer Registry of Norway (CRN), Oslo, Norway
| | | | - Michael B Mortensen
- Danish Pancreatic Cancer Group, HPB Section, Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Maja Primic-Žakelj
- Epidemiology and Cancer Registry, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | - Vesna Zadnik
- Epidemiology and Cancer Registry, Institute of Oncology Ljubljana, Ljubljana, Slovenia
| | | | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Margit Mägi
- Estonian Cancer Registry, National Institute for Health Development, Tallinn, Estonia
| | - Tiziana Cassetti
- Pancreatic Cancer Registry of Reggio Emilia Province, Unit of Gastroenterology and Digestive Endoscopy AUSL-RE, Local Health Authority-IRCCS, Reggio Emilia, Italy
| | - Romano Sassatelli
- Pancreatic Cancer Registry of Reggio Emilia Province, Unit of Gastroenterology and Digestive Endoscopy AUSL-RE, Local Health Authority-IRCCS, Reggio Emilia, Italy
| | - Robert Grützmann
- Department of Surgery, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Susanne Merkel
- Department of Surgery, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Ana F Gonçalves
- Departments of Epidemiology, Portuguese Oncology Institute of Porto (IPOP), Porto, Portugal
| | - Maria J Bento
- Departments of Epidemiology, Portuguese Oncology Institute of Porto (IPOP), Porto, Portugal
| | - Péter Hegyi
- Institute for Translational Medicine, University of Pécs, Pécs, Hungary
| | - Gábor Lakatos
- Department of Oncology, St. Istvan and St. Laszlo Hospital and Out-Patient Department, Budapest, Hungary
| | - Andrea Szentesi
- Institute for Translational Medicine, University of Pécs, Pécs, Hungary
| | - Michel Moreau
- Department of Surgical Oncology, Jules Bordet Institute (IJB), Brussels, Belgium
| | - Tony van de Velde
- Biometrics Department, The Netherlands Cancer Institute (NKI), Amsterdam, Netherlands
| | - Annegien Broeks
- Biometrics Department, The Netherlands Cancer Institute (NKI), Amsterdam, Netherlands
| | - Milena Sant
- Analytical Epidemiology and Health Impact Unit, Department of Preventive and Predictive Medicine, Fondazione IRCCS, Istituto Nazionale dei Tumori (INT), Milan, Italy
| | - Pamela Minicozzi
- Analytical Epidemiology and Health Impact Unit, Department of Preventive and Predictive Medicine, Fondazione IRCCS, Istituto Nazionale dei Tumori (INT), Milan, Italy
| | - Vincenzo Mazzaferro
- Hepato-Biliary Surgery Unit, Istituto Nazionale dei Tumori (INT), and University of Milan, Milan, Italy
| | - Francisco X Real
- Epithelial Carcinogenesis Group, Spanish National Cancer Research Centre (CNIO), CIBERONC, Madrid, Spain.,Department de Ciencies Experimentals i de la, Universitat Pompeu Fabra, Barcelona, Spain
| | - Alfredo Carrato
- Department of Oncology, Ramon y Cajal University Hospital, IRYCIS, Alcala University, CIBERONC, Madrid, Spain
| | - Xavier Molero
- Hospital Universitari Vall d'Hebron, Exocrine Pancreas Research Unit and Vall d'Hebron Research Institute (VHIR), Universitat Autonoma de Barcelona, Campus de la UAB, Barcelona, Spain.,CIBEREHD and CIBERESP, Madrid, Spain
| | - Marc G Besselink
- Dutch Pancreatic Cancer Group, Academic Medical Centre Amsterdam, Amsterdam, Netherlands
| | - Núria Malats
- Geneticand Molecular Epidemiology Group, Spanish National Cancer Research Centre (CNIO), CIBERONC, ISCIII, Madrid, Spain
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Petra Schrotz-King
- Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany.,German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany.,Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), Heidelberg, Germany
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21
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Nieveen van Dijkum EJM. ASO Author Reflections: Pancreatic Neuroendocrine Tumor Recurrence and Survival Predicted by Ki67. Ann Surg Oncol 2018; 26:531-532. [PMID: 30519760 PMCID: PMC6901402 DOI: 10.1245/s10434-018-7019-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Indexed: 12/20/2022]
Affiliation(s)
- Els J M Nieveen van Dijkum
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
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22
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Vonlanthen R, Lodge P, Barkun JS, Farges O, Rogiers X, Soreide K, Kehlet H, Reynolds JV, Käser SA, Naredi P, Borel-rinkes I, Biondo S, Pinto-marques H, Gnant M, Nafteux P, Ryska M, Bechstein WO, Martel G, Dimick JB, Krawczyk M, Oláh A, Pinna AD, Popescu I, Puolakkainen PA, Sotiropoulos GC, Tukiainen EJ, Petrowsky H, Clavien P. Toward a Consensus on Centralization in Surgery. Ann Surg 2018; 268:712-24. [DOI: 10.1097/sla.0000000000002965] [Citation(s) in RCA: 127] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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23
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Sabater L, Muñoz E, Roselló S, Dorcaratto D, Garcés-Albir M, Huerta M, Roda D, Gómez-Mateo MC, Ferrández-Izquierdo A, Darder A, Cervantes A. Borderline resectable pancreatic cancer. Challenges and controversies. Cancer Treat Rev 2018; 68:124-135. [PMID: 29957372 DOI: 10.1016/j.ctrv.2018.06.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 06/11/2018] [Accepted: 06/12/2018] [Indexed: 12/18/2022]
Abstract
Pancreatic cancer is a dismal disease with an increasing incidence. Despite the majority of patients are not candidates for curative surgery, a subgroup of patients classified as borderline resectable pancreatic cancer can be selected in whom a sequential strategy of neoadjuvant therapy followed by surgery can provide better outcomes. Multidisciplinary approach and surgical pancreatic expertise are essential for successfully treating these patients. However, the lack of consensual definitions and therapies make the results of studies very difficult to interpret and hard to be implemented in some settings. In this article, we review the challenges of borderline resectable pancreatic cancer, the complexity of its management and controversies and point out where further research and international cooperation for a consensus strategy is urgently needed.
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Affiliation(s)
- Luis Sabater
- Department of Surgery, Liver-Biliary and Pancreatic Unit, Biomedical Research Institute INCLIVA, Hospital Clinico University of Valencia, Spain
| | - Elena Muñoz
- Department of Surgery, Liver-Biliary and Pancreatic Unit, Biomedical Research Institute INCLIVA, Hospital Clinico University of Valencia, Spain
| | - Susana Roselló
- CIBERONC Department of Medical Oncology, Biomedical Research Institute INCLIVA, University of Valencia, Spain
| | - Dimitri Dorcaratto
- Department of Surgery, Liver-Biliary and Pancreatic Unit, Biomedical Research Institute INCLIVA, Hospital Clinico University of Valencia, Spain
| | - Marina Garcés-Albir
- Department of Surgery, Liver-Biliary and Pancreatic Unit, Biomedical Research Institute INCLIVA, Hospital Clinico University of Valencia, Spain
| | - Marisol Huerta
- CIBERONC Department of Medical Oncology, Biomedical Research Institute INCLIVA, University of Valencia, Spain
| | - Desamparados Roda
- CIBERONC Department of Medical Oncology, Biomedical Research Institute INCLIVA, University of Valencia, Spain
| | | | | | - Antonio Darder
- Department of Surgery, Liver-Biliary and Pancreatic Unit, Biomedical Research Institute INCLIVA, Hospital Clinico University of Valencia, Spain
| | - Andrés Cervantes
- CIBERONC Department of Medical Oncology, Biomedical Research Institute INCLIVA, University of Valencia, Spain.
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24
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Ahola R, Hölsä H, Kiskola S, Ojala P, Pirttilä A, Sand J, Laukkarinen J. Access to radical resections of pancreatic cancer is region-dependent despite the public healthcare system in Finland. J Epidemiol Community Health 2018; 72:803-808. [PMID: 29720389 DOI: 10.1136/jech-2017-210187] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 03/23/2018] [Accepted: 04/16/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND Surgical resection is the best treatment option to improve the prognosis of pancreatic cancer (PC). Our aim was to analyse whether PC treatment strategies show regional variation in Finland, a country with a nationwide public healthcare system. METHODS All patients diagnosed with PC in 2003 and 2008 were identified from the Finnish Cancer Registry. The data regarding tumour, treatment, demographics and timespans to treatment were recorded from the patient archives. Patients were included in the healthcare district where the diagnosis was made. The healthcare districts were classified according to experience in pancreatic surgery into three groups (high level of experience region (HLER), n=2; medium level of experience region (MLER), n=6, and low level of experience region (LLER), n=13). RESULTS Patients included numbered 1546 (median age 72 years (range 34-97), 45% men). Demographics and the ratio of stage IV disease (53%) were similar between the regional groups. Despite this, the proportion of radical surgery was greater in HLERs than in the MLERs and LLERs (18% vs 8%-11%; p<0.01). Logistic regression analysis including age, American Society of Anesthesiologists classification, stage and level of experience showed that more radical resections were performed in the HLERs. Preoperative bile drainage showed no regional differences (p=0.137). Palliative chemotherapy only was used more frequently in MLER and LLER than in HLERs (24% vs 33%-30%; p<0.01). CONCLUSION Access to PC curative treatment was more likely for patients in healthcare districts including a hospital with high level of experience in pancreatic surgery. This highlights the importance of centralized treatment guidance.
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Affiliation(s)
- Reea Ahola
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - Heini Hölsä
- Medicine, University of Tampere, Tampere, Finland
| | | | - Pirkka Ojala
- Medicine, University of Tampere, Tampere, Finland
| | | | - Juhani Sand
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - Johanna Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland.,Medicine, University of Tampere, Tampere, Finland
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25
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Faron M, Vuarnesson H, Boher JM, Bachellier P, Sauvanet A, Sa Cunha A, Le Treut YP, Mabrut JY, Delpero JR, Paye F. How to Reliably Assess Nodal Status in Distal Pancreatectomy for Adenocarcinoma. Pancreas 2018; 47:308-13. [PMID: 29351122 DOI: 10.1097/MPA.0000000000000992] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVES The optimal number of lymph nodes that need to be analyzed to reliably assess nodal status in distal pancreatectomy for adenocarcinoma is still unknown. METHODS Two hundred seventy-eight patients who underwent distal pancreatectomy for adenocarcinoma were retrieved from a retrospective French nationwide database. The relations between the number of analyzed lymph nodes and the nodal status of the tumor were studied. The beta-binomial law was used to estimate the probability of being truly node negative depending on the number of analyzed lymph nodes. Cox proportional hazard model was used for the survival analysis. RESULTS The median number of analyzed lymph nodes was 15. There was a positive correlation between the number of positive lymph nodes and the number of lymph nodes analyzed. The curve reached a plateau at approximately 25 lymph nodes. The beta binomial model demonstrated that an analysis of 21 negative lymph nodes shows a probability to be truly N0 at 95%. N+ status was associated with survival, but the number of lymph node analyzed was not. CONCLUSION At least 21 lymph nodes should be analyzed to ensure a reliable assessment of the nodal status, but this number may be hard to reach in distal pancreatectomy.
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26
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Klompmaker S, de Rooij T, van Hilst J, Besselink MG. Systematic Training for Safe Implementation of Minimally Invasive Pancreatic Surgery. Minimally Invasive Surgery of the Pancreas 2018. [DOI: 10.1007/978-88-470-3958-2_4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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27
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Mesman R, Faber MJ, Berden BJ, Westert GP. Evaluation of minimum volume standards for surgery in the Netherlands (2003–2017): A successful policy? Health Policy 2017; 121:1263-1273. [DOI: 10.1016/j.healthpol.2017.09.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 09/16/2017] [Accepted: 09/19/2017] [Indexed: 01/29/2023]
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28
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Lykoudis PM, Partelli S, Muffatti F, Caplin M, Falconi M, Fusai GK. Treatment challenges in and outside a specialist network setting: Pancreatic neuroendocrine tumours. Eur J Surg Oncol 2017; 45:46-51. [PMID: 29126671 DOI: 10.1016/j.ejso.2017.08.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 08/18/2017] [Indexed: 01/14/2023] Open
Abstract
Pancreatic Neuroendocrine Neoplasms comprise a group of rare tumours with special biology, an often indolent behaviour and particular diagnostic and therapeutic requirements. The specialized biochemical tests and radiological investigations, the complexity of surgical options and the variety of medical treatments that require individual tailoring, mandate a multidisciplinary approach that can be optimally achieved through an organized network. The present study describes currents concepts in the management of these tumours as well as an insight into the challenges of delivering the pathway in and outside a Network.
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Affiliation(s)
- Panagis M Lykoudis
- Department of Hepato-Pancreato-Biliary Surgery & Liver Transplantation, Royal Free Hospital, London, UK.
| | - Stefano Partelli
- Pancreatic Surgery Unit, Pancreas Translational & Research Institute, Scientific Institute San Raffaele Hospital & University "Vita e Salute", Milan, Italy
| | - Francesca Muffatti
- Pancreatic Surgery Unit, Pancreas Translational & Research Institute, Scientific Institute San Raffaele Hospital & University "Vita e Salute", Milan, Italy
| | - Martyn Caplin
- Department of Gastroenterology and G.I. & Tumour Neuroendocrinology, Royal Free Hospital, London, UK
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational & Research Institute, Scientific Institute San Raffaele Hospital & University "Vita e Salute", Milan, Italy
| | - Giuseppe K Fusai
- Department of Hepato-Pancreato-Biliary Surgery & Liver Transplantation, Royal Free Hospital, London, UK
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29
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Scheufele F, Schorn S, Demir IE, Sargut M, Tieftrunk E, Calavrezos L, Jäger C, Friess H, Ceyhan GO. Preoperative biliary stenting versus operation first in jaundiced patients due to malignant lesions in the pancreatic head: A meta-analysis of current literature. Surgery 2017; 161:939-950. [DOI: 10.1016/j.surg.2016.11.001] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Revised: 10/23/2016] [Accepted: 11/01/2016] [Indexed: 12/13/2022]
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30
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Mosquera C, Vohra NA, Fitzgerald TL, Zervos EE. Discharge with Pancreatic Fistula after Pancreaticoduodenectomy Independently Predicts Hospital Readmission. Am Surg 2016. [DOI: 10.1177/000313481608200827] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Readmission rates after pancreaticoduodenectomy (PD) are among the highest of any surgical procedure. The purpose of this study was to identify those factors present at discharge that may predict readmission after PD. All patients undergoing PD between 2010 and 2015 at a very high (>35 PD/year) volume center were entered into a prospective database. Twenty factors present at discharge from index admission identified on univariate analysis were subjected to multivariate analysis to identify those independently predictive of 30-day hospital readmission. A total of 220 patients underwent PD during the study period, 88 per cent of which had cancer. Mean age was 64.4 ± 11.7 years with slight male preponderance (54.5%) and significant African American representation (33.2%). Surgical complications occurred in 67.3 per cent of patients the most common of which included infectious/leak (30%), gastrointestinal (29%), cardiorespiratory (13%), other (13%), minor complications (7%), multi system failure (5%), and new onset diabetes (3%). The 30-day readmission rate was 27.3 per cent and was due to infection (89%), failure to thrive (32%), nausea/vomiting (15%), or other (15%). On multivariate analysis, presence of pancreatic leak/fistula at discharge was the only significant predictor of readmission, present in 62.5 per cent of all readmitted patients ( P = 0.001). Comorbidities, length of stay, insurance status, obesity, smoking, and discharge to a care venue other than home did not predict readmission. Patients manifesting pancreatic fistula after PD are at high risk for hospital readmission. Enhanced scrutiny regarding suitability for discharge should be exercised in these patients and measures taken to minimize readmission whenever possible.
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Affiliation(s)
- Catalina Mosquera
- Division of Surgical Oncology, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Nasreen A. Vohra
- Division of Surgical Oncology, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Timothy L. Fitzgerald
- Division of Surgical Oncology, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Emmanuel E. Zervos
- Division of Surgical Oncology, Brody School of Medicine, East Carolina University, Greenville, North Carolina
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