Abstract
Background
Despite the close relationship between hospital volume and mortality after pancreaticoduodenectomy (PD), the role of surgeon volume still remains an open issue. Retrospective multi-institutional reviews considered only in-hospital mortality, whereas no data about major complications are available so far. The aim of this study is to assess the independent impact of surgeon volume on outcome after PD in a single high-volume institution.
Methods
Demographics and clinical and surgical variables were prospectively collected on 610 patients who underwent PD from August 2001 to August 2009. The cutoff value to categorize high- and low-volume surgeons (HVS and LVS, respectively) was 12 PD/year. The primary endpoint was operative mortality (death within 30-day post-discharge). Secondary endpoints were morbidity, pancreatic fistula (PF), and length of hospital stay (LOS).
Results
In the whole series, mortality was 4.1%, overall morbidity was 61.3%, and PF rate was 27.5%. Two HVS performed 358 PD (58.6%), while six LVS performed 252 PD (41.4%). Mortality was 3.9% for HVS and 4.3% for LVS (p = 0.84). The major complication rate was similar for HVS and LVS (14.5% vs. 16.2%). The PF rate was higher for LVS (32.4% vs. 24.1%, p = 0.03). The mean LOS was 15.5 days for HVS vs. 16.9 days for LVS (p = 0.11). At multivariate analysis, risk factors for PF occurrence were LVS, soft pancreatic stump, small duct diameter, and longer operative time.
Conclusion
Low-volume surgeons had a higher PF rate. However, this did not increase mortality and major morbidity rates probably because of the protective effect of high-volume hospital in improving patient rescue from life-threatening complications.
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References
Cameron JL, Riall TS, Coleman J, Belcher KA. One thousand consecutive pancreaticoduodenectomies. Ann Surg 2006; 244:10–15.
Balcom JH 4th, Rattner DW, Warshaw AL, Chang Y, Fernandez-del Castillo C. Ten-year experience with 733 pancreatic resections: changing indications, older patients, and decreasing length of hospitalization. Arch Surg 2001; 136: 391–398.
Kotwall CA, Maxwell JG, Brinker CC, Koch GG, Covington DL. National estimates of mortality rates for radical pancreaticoduodenectomy in 25000 patients. Ann Surg Oncol 2002; 9: 847–854.
Birkmeyer JD, Siewers AE, Finlayson EV, Stukel TA, Lucas FL, Batista I, Welch HG, Wennberg DE. Hospital volume and surgical mortality in the United States. N Engl J Med 2002; 346: 1128–1137.
Ho V, Heslin MJ. Effect of hospital volume and experience on in-hospital mortality for pancreaticoduodenectomy. Ann Surg 2003; 237: 509–514.
Gouma DJ, van Geenen RC, van Gulik TM, de Haan RJ, de Wit LT, Busch OR, Obertop H. Rates of complications and death after pancreaticoduodenectomy: risk factors and the impact of hospital volume. Ann Surg 2000; 232: 786–795.
van Heek NT, Kuhlmann KF, Scholten RJ, de Castro SM, Busch OR, van Gulik TM, Obertop H, Gouma DJ. Hospital volume and mortality after pancreatic resection: a systematic review and an evaluation of intervention in the Netherlands. Ann Surg 2005; 242: 781–790.
M.W. Buchler, M. Wagner, B.M. Schmied, W. Uhl, H. Friess and K. Z’Graggen, Changes in morbidity after pancreatic resection: toward the end of completion pancreatectomy. Arch Surg 2003; 138:1310–1314
Balzano G, Zerbi A, Capretti G, Rocchetti S, Capitanio V, Di Carlo V. Effect of hospital volume on the outcome of pancreaticoduodenectomy in Italy. Br J Surg 2008; 95:357–362.
Chowdhury MM, Dagash H, Pierro A. A systematic review of the impact of volume of surgery and specialization on patient outcome. Br J Surg 2007; 94: 145–161.
Lieberman MD, Kilburn H, Lindsey M, Brennan MF. Relation of perioperative deaths to hospital volume among patients undergoing pancreatic resection for malignancy. Ann Surg 1995; 222:638–645.
Nathan H, Cameron JL, Choti MA, Schulick RD, Pawlik TM. The volume-outcomes effect in hepato-pancreato-biliary surgery: hospital versus surgeon contributions and specificity of the relationship. J Am Coll Surg 2009; 208:528–538.
Balzano G, Zerbi A, Braga M, Rocchetti S, Beneduce AA, Di Carlo V. Fast-track recovery programme after pancreatico- duodenectomy reduces delayed gastric emptying. Br J Surg 2008; 95:1387–1393.
Schmidt CM, Turrini O, Parikh P, House MG, Zyromski NJ, Nakeeb A, Howard TJ, Pitt HA, Lillemoe KD. Effect of hospital volume, surgeon experience, and surgeon volume on patient outcomes after pancreaticoduodenectomy: a single-institution experience. Arch Surg 2010;145: 634–40.
Bozzetti F, Braga M, Gianotti L, Gavazzi C, Mariani L. Postoperative enteral versus parenteral nutrition in malnourished patients with gastrointestinal cancer: a randomised multicentre trial. Lancet 2001; 358: 1487–1492.
Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, Neoptolemos J, Sarr M, Traverso W, Buchler M, International Study Group on Pancreatic Fistula Definition. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 2005; 138:8–13.
Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004; 240:205–213
DeOliveira ML, Winter JM, Schafer M, Cunningham SC, Cameron JL, Yeo CJ, Clavien PA. Assessment of complications after pancreatic surgery: A novel grading system applied to 633 patients undergoing pancreaticoduodenectomy. Ann Surg 2006; 244:931–937
Seiler CA, Wagner M, Bachmann T, Redaelli CA, Schmied B, Uhl W, Friess H, Büchler MW. Randomized clinical trial of pylorus-preserving duodenopancreatectomy versus classical Whipple resection-long term results. Br J Surg 2005; 92:547–556.
Duffas JP, Suc B, Msika S, Fourtanier G, Muscari F, Hay JM, Fingerhut A, Millat B, Radovanowic A, Fagniez PL; French Associations for Research in Surgery. A controlled randomized multicenter trial of pancreatogastrostomy or pancreatojejunostomy after pancreatoduodenectomy. Am J Surg. 2005; 189:720–729.
Wente MN, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Izbicki JR, Neoptolemos JP, Padbury RT, Sarr MG, Traverso LW, Yeo CJ, Büchler MW. Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery 2007; 142:761–768.
Eppsteiner RW, Csikesz NG, McPhee JT, Tseng JF, Shah SA. Surgeon volume impacts hospital mortality for pancreatic resection. Ann Surg 2009; 249: 635–640.
Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL. Surgeon volume and operative mortality in the United States. N Engl J Med 2003; 349: 2117–2127.
Winter JM, Cameron JL, Campbell KA, Chang DC, Riall TS, Schulick RD, Choti MA, Coleman J, Hodgin MB, Sauter PK, Sonnenday CJ, Wolfgang CL, Marohn MR, Yeo CJ. Does pancreatic duct stenting decrease the rate of pancreatic fistula following pancreaticoduodenectomy? Results of a prospective randomized trial. J Gastrointest Surg 2006; 10:1280–1290
Pratt WB, Maithel SK, Vanounou T, Huang ZS, Callery MP, Vollmer CM Jr. Clinical and economic validation of the International Study Group of Pancreatic Fistula (ISGPF) classification scheme. Ann Surg 2007; 245:443–451
Ghaferi AA, Osborne NH, Birkmeyer JD, Dimick JB. Hospital Characteristics Associated with Failure to Rescue from Complications after Pancreatectomy. J Am Coll Surg 2010; 211:325–330.
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Pecorelli, N., Balzano, G., Capretti, G. et al. Effect of Surgeon Volume on Outcome Following Pancreaticoduodenectomy in a High-Volume Hospital. J Gastrointest Surg 16, 518–523 (2012). https://doi.org/10.1007/s11605-011-1777-2
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DOI: https://doi.org/10.1007/s11605-011-1777-2