Effect of centralization on long-term survival after resection of pancreatic ductal adenocarcinoma

BACKGROUND

Centralization of pancreatic surgery has resulted in improved short-term outcomes in a number of healthcare systems. The aim of this study was to see whether hospital volume influenced long-term prognosis, use of adjuvant therapy or histopathological evaluation of patients undergoing surgical resection for pancreatic ductal adenocarcinoma (PDAC).

METHODS

Patients undergoing surgical resection of PDAC in Finland between 2002 and 2008 were identified from national registers. Demographic, histopathological, operative and oncological data were recorded, and the histopathological slides of patients who survived for more than 4 years were reviewed. Operative volume was defined according to the annual rate of pancreatoduodenectomy as: high-volume centres (HVCs; 20 or more resections per year), medium-volume centres (MVCs; 6-19 resection annually) and low-volume centres (LVCs; 5 or fewer resections annually).

RESULTS

Some 467 patients who had undergone resectional surgery for PDAC at 22 centres were included. Patient demographics and resection types did not differ between centres. Thirty- and 90-day mortality rates were significantly lower in HVCs compared with LVCs: 0 versus 5·5 per cent (P = 0·001) and 2·5 versus 11·0 per cent (P = 0·003) respectively. Tumours in HVCs were generally at a more advanced stage than those in LVCs (stage IIB: 65·7 versus 40·6 per cent respectively; P < 0·001), but with no greater use of adjuvant therapy. Significantly more patients survived for 2 years (43·3 versus 29·7 per cent; P = 0·034) and 3 years (25·4 versus 14·1 per cent; P = 0·045) after surgery in HVCs than in LVCs. More information was missing in the histopathological reports from LVCs and MVCs than in those from HVCs (P ≤ 0·002).

CONCLUSION

Both short- and long-term survival was significantly better for patients operated on in HVCs. Histopathological analysis appears to be more comprehensive in HVCs.

ERCP procedures in a Finnish community hospital: a retrospective analysis of 1207 cases

BACKGROUND AND AIMS

Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure with a risk of serious and life-threatening complications. The most common complications are pancreatitis, haemorrhage, perforation and cholangitis. The aim of this study was to determine indications, success rates and complications in a low-volume ERCP unit in Kanta-Häme Central Hospital (KHCH).

MATERIAL AND METHODS

Data on 1207 consecutive ERCPs performed in KHCH between 2002 and 2009 was collected retrospectively from patient histories. Complications were classified according to need for intervention and length of hospitalisation.

RESULTS

Cannulation of the desired duct was successful in 89.2% of 825 ERCPs with no earlier sphincterotomy. Complete stone removal was achieved in 91.3% of procedures. Standard biliary sphincterotomy was performed in 73.8% and precut sphincterotomy in 12.0 % of cases. Cholangitis developed in 2.1%, bleeding in 1.9%, pancreatitis in 1.9%, perforation in 1.0% and cardio-pulmonary or miscellaneous complications in 4.2% of cases. The majority of complications could be managed conservatively. In procedures with no earlier sphincterotomy ERCP-related 30-day mortality was 0.2% (n=2) and overall 30-day mortality was 3.3% (n=27).

CONCLUSIONS

ERCP indications and success rates, as well as morbidity and mortality were comparable to those re-ported earlier. Although the success rate of cannulation and thereby ERCP procedures seem to be somewhat lower than in tertiary referral centres, ERCP procedures can be safely performed in a low-volume ERCP unit by concentrating procedures on a few experienced endoscopists. The success rates may be further improved with the latest cannulation techniques, used selectively in the last years of the study period.