World Journal of Surgery

, Volume 38, Issue 6, pp 1484–1490 | Cite as

Pancreaticoduodenectomy: Outcomes in a Low-Volume, Specialised Hepato Pancreato Biliary Unit

  • H. A. Kanhere
  • M. I. Trochsler
  • M. H. Kanhere
  • A. N. Lord
  • G. J. Maddern



This study was designed to evaluate the outcomes of pancreaticoduodenectomy (PD) at a low-volume specialised Hepato Pancreato Biliary (HPB) unit. Volume outcome analyses show significantly better results for patients undergoing PD at high-volume centres (Begg et al. JAMA 280:1747–1751, 1998; Finlayson et al. Arch Surg 138:721–725, 2003; Birkmeyer et al. N Engl J Med 346:1128–1137, 2002; Gouma et al. Ann Surg 232:786–795, 2000). Centralisation of PD seems to be the logical conclusion to be drawn from these results. In countries like Australia with a small and widely dispersed population, centralisation may not be always feasible. Alternative strategy would be to have similar systems in place to those in high-volume centres to achieve similar results at low-volume centres. Many Australian tertiary care centres perform low to medium volumes of PD (Chen et al. HPB 12:101–108, 2010; Kwok et al. ANZ J Surg 80:605–608, 2010; Barnett and Collier ANZ J Surg 76:563–568, 2006; Samra et al. Hepatobiliary Pancreat Dis Int 10:415–421, 2011). Most of these have a specialised HPB unit, accredited by the Australia and New Zealand Hepatic pancreatic and biliary association (ANZHPBA), as training units for post fellowship training in HPB surgery. It is imperative to perform outcome-based analyses in these units to ensure safety and high quality of care.


Retrospective analysis of database for periampullary carcinoma (1998 till date) was performed in an ANZHPBA accredited HPB unit based at a tertiary care teaching hospital in South Australia. Because age older than 74 years is shown to be a predictive marker of increased morbidity and mortality after a PD, we analysed the outcomes in this subset of patients separately.


Fifty-three patients underwent PD in 14 years. Overall mortality was 3.8 %. The last in hospital mortality was in 1999. The morbidity rates and the oncologic outcomes were similar to those in high-volume units.


PD can be safely performed in a low-volume specialised unit at centres where the amenities and processes at high-volume centres can be replicated.


  1. 1.
    Begg CB, Cramer LD, Hoskins WJ, Brennan MF (1998) Impact of hospital volume on operative mortality for major cancer surgery. JAMA 280(20):1747–1751PubMedCrossRefGoogle Scholar
  2. 2.
    Finlayson EV, Goodney PP, Birkmeyer JD (2003) Hospital volume and operative mortality in cancer surgery: a national study. Arch Surg 138(7):721–725. doi:10.1001/archsurg.138.7.721 discussion 726PubMedCrossRefGoogle Scholar
  3. 3.
    Birkmeyer JD, Siewers AE, Finlayson EV, Stukel TA, Lucas FL, Batista I, Welch HG, Wennberg DE (2002) Hospital volume and surgical mortality in the United States. N Engl J Med 346(15):1128–1137. doi:10.1056/NEJMsa012337 PubMedCrossRefGoogle Scholar
  4. 4.
    Gouma DJ, van Geenen RC, van Gulik TM, de Haan RJ, de Wit LT, Busch OR, Obertop H (2000) Rates of complications and death after pancreaticoduodenectomy: risk factors and the impact of hospital volume. Ann Surg 232(6):786–795PubMedCentralPubMedCrossRefGoogle Scholar
  5. 5.
    Chen JW, Bhandari M, Astill DS, Wilson TG, Kow L, Brooke-Smith M, Toouli J, Padbury RT (2010) Predicting patient survival after pancreaticoduodenectomy for malignancy: histopathological criteria based on perineural infiltration and lymphovascular invasion. HPB (Oxford) 12(2):101–108. doi:10.1111/j.1477-2574.2009.00140.x CrossRefGoogle Scholar
  6. 6.
    Kwok KH, Rizk J, Coleman M, Fenton-Lee D (2010) Pancreaticoduodenectomy—outcomes from an Australian institution. ANZ J Surg 80(9):605–608. doi:10.1111/j.1445-2197.2010.05348.x PubMedCrossRefGoogle Scholar
  7. 7.
    Barnett SA, Collier NA (2006) Pancreaticoduodenectomy: does preoperative biliary drainage, method of pancreatic reconstruction or age influence perioperative outcome? A retrospective study of 104 consecutive cases. ANZ J Surg 76(7):563–568. doi:10.1111/j.1445-2197.2006.03778.x PubMedCrossRefGoogle Scholar
  8. 8.
    Samra JS, Bachmann RA, Choi J, Gill A, Neale M, Puttaswamy V, Bell C, Norton I, Cho S, Blome S, Maher R, Gananadha S, Hugh TJ (2011) One hundred and seventy-eight consecutive pancreatoduodenectomies without mortality: role of the multidisciplinary approach. Hepatobiliary Pancreat Dis Int 10(4):415–421PubMedCrossRefGoogle Scholar
  9. 9.
    Topal B, Van de Sande S, Fieuws S, Penninckx F (2007) Effect of centralization of pancreaticoduodenectomy on nationwide hospital mortality and length of stay. Br J Surg 94(11):1377–1381. doi:10.1002/bjs.5861 PubMedCrossRefGoogle Scholar
  10. 10.
    de Wilde RF, Besselink MG, van der Tweel I, de Hingh IH, van Eijck CH, Dejong CH, Porte RJ, Gouma DJ, Busch OR, Molenaar IQ, Dutch Pancreatic Cancer Group (2012) Impact of nationwide centralization of pancreaticoduodenectomy on hospital mortality. Br J Surg 99(3):404–410. doi:10.1002/bjs.8664 PubMedCrossRefGoogle Scholar
  11. 11.
    Parikh P, Shiloach M, Cohen ME, Bilimoria KY, Ko CY, Hall BL, Pitt HA (2010) Pancreatectomy risk calculator: an ACS-NSQIP resource. HPB (Oxford) 12(7):488–497. doi:10.1111/j.1477-2574.2010.00216.x CrossRefGoogle Scholar
  12. 12.
    Maisonneuve P, Lowenfels AB (2010) Epidemiology of pancreatic cancer: an update. Dig Dis 28(4–5):645–656. doi:10.1159/000320068 PubMedCrossRefGoogle Scholar
  13. 13.
    Trochsler MTST, Kanhere HA (2011) Pancreatic surgery. In: Wichmann M, Caron N, Maddern G (eds) Rural surgery. Springer, Berlin, pp 187–194CrossRefGoogle Scholar
  14. 14.
    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 (2005) Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery 138(1):8–13. doi:10.1016/j.surg.2005.05.001 PubMedCrossRefGoogle Scholar
  15. 15.
    Lieberman MD, Kilburn H, Lindsey M, Brennan MF (1995) Relation of perioperative deaths to hospital volume among patients undergoing pancreatic resection for malignancy. Ann Surg 222(5):638–645PubMedCentralPubMedCrossRefGoogle Scholar
  16. 16.
    Welfare A (2006) World population prospects: the 2006 RevisionGoogle Scholar
  17. 17.
    Allareddy V, Ward MM, Allareddy V, Konety BR (2010) Effect of meeting Leapfrog volume thresholds on complication rates following complex surgical procedures. Ann Surg 251(2):377–383. doi:10.1097/SLA.0b013e3181cb853f PubMedCrossRefGoogle Scholar
  18. 18.
    Massarweh NN, Flum DR, Symons RG, Varghese TK, Pellegrini CA (2011) A critical evaluation of the impact of Leapfrog’s evidence-based hospital referral. J Am Coll Surg 212(2):150–159. doi:10.1016/j.jamcollsurg.2010.09.027 PubMedCrossRefGoogle Scholar
  19. 19.
    Winter JM, Cameron JL, Campbell KA, Arnold MA, Chang DC, Coleman J, Hodgin MB, Sauter PK, Hruban RH, Riall TS, Schulick RD, Choti MA, Lillemoe KD, Yeo CJ (2006) 1423 Pancreaticoduodenectomies for pancreatic cancer: a single-institution experience. J Gastrointest Surg 10(9):1199–1210. doi:10.1016/j.gassur.2006.08.018 PubMedCrossRefGoogle Scholar
  20. 20.
    Schmidt CM, Powell ES, Yiannoutsos CT, Howard TJ, Wiebke EA, Wiesenauer CA, Baumgardner JA, Cummings OW, Jacobson LE, Broadie TA, Canal DF, Goulet RJ Jr, Curie EA, Cardenes H, Watkins JM, Loehrer PJ, Lillemoe KD, Madura JA (2004) Pancreaticoduodenectomy: a 20-year experience in 516 patients. Arch Surg 139(7):718–725. doi:10.1001/archsurg.139.7.718 PubMedCrossRefGoogle Scholar
  21. 21.
    Teh SH, Diggs BS, Deveney CW, Sheppard BC (2009) Patient and hospital characteristics on the variance of perioperative outcomes for pancreatic resection in the United States: a plea for outcome-based and not volume-based referral guidelines. Arch Surg 144(8):713–721. doi:10.1001/archsurg.2009.67 PubMedCrossRefGoogle Scholar
  22. 22.
    Emick DM, Riall TS, Cameron JL, Winter JM, Lillemoe KD, Coleman J, Sauter PK, Yeo CJ (2006) Hospital readmission after pancreaticoduodenectomy. J Gastrointest Surg 10(9):1243–1252. doi:10.1016/j.gassur.2006.08.016 discussion 1252-1243PubMedCrossRefGoogle Scholar
  23. 23.
    Sohn TA, Yeo CJ, Cameron JL, Geschwind JF, Mitchell SE, Venbrux AC, Lillemoe KD (2003) Pancreaticoduodenectomy: role of interventional radiologists in managing patients and complications. J Gastrointest Surg 7(2):209–219PubMedCrossRefGoogle Scholar
  24. 24.
    Milstein A, Galvin RS, Delbanco SF, Salber P, Buck CR Jr (2000) Improving the safety of health care: the leapfrog initiative. Eff Clin Pract 3(6):313–316PubMedGoogle Scholar
  25. 25.
    Sohn TA, Yeo CJ, Cameron JL, Lillemoe KD, Talamini MA, Hruban RH, Sauter PK, Coleman J, Ord SE, Grochow LB, Abrams RA, Pitt HA (1998) Should pancreaticoduodenectomy be performed in octogenarians? J Gastrointest Surg 2(3):207–216PubMedCrossRefGoogle Scholar
  26. 26.
    Prashant S, Jonathan T, Mauricio S, James S, Peter D (2012) Advanced age is a risk factor for postoperative complications and mortality after a pancreaticoduodenectomy: a meta-analysis and systematic review. HPB (Oxford) 14(10):649–657. doi:10.1111/j.1477-2574.2012.00506.x CrossRefGoogle Scholar
  27. 27.
    Riall TS, Nealon WH, Goodwin JS, Townsend CM Jr, Freeman JL (2008) Outcomes following pancreatic resection: variability among high-volume providers. Surgery 144(2):133–140. doi:10.1016/j.surg.2008.03.041 PubMedCentralPubMedCrossRefGoogle Scholar
  28. 28.
    Kingsnorth AN (2000) Major HPB procedures must be undertaken in high volume quaternary centres? HPB Surg 11(5):359–361PubMedCentralPubMedCrossRefGoogle Scholar
  29. 29.
    Yeo CJ, Cameron JL, Sohn TA, Coleman J, Sauter PK, Hruban RH, Pitt HA, Lillemoe KD (1999) Pancreaticoduodenectomy with or without extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma: comparison of morbidity and mortality and short-term outcome. Ann Surg 229(5):613–622 discussion 622-624PubMedCentralPubMedCrossRefGoogle Scholar
  30. 30.
    La Torre M, Nigri G, Ferrari L, Cosenza G, Ravaioli M, Ramacciato G (2012) Hospital volume, margin status, and long-term survival after pancreaticoduodenectomy for pancreatic adenocarcinoma. Am Surg 78(2):225–229PubMedGoogle Scholar
  31. 31.
    Gutierrez JC, Franceschi D, Koniaris LG (2008) How many lymph nodes properly stage a periampullary malignancy? J Gastrointest Surg 12(1):77–85. doi:10.1007/s11605-007-0251-7 PubMedCrossRefGoogle Scholar
  32. 32.
    Hellan M, Sun CL, Artinyan A, Mojica-Manosa P, Bhatia S, Ellenhorn JD, Kim J (2008) The impact of lymph node number on survival in patients with lymph node-negative pancreatic cancer. Pancreas 37(1):19–24. doi:10.1097/MPA.0b013e31816074c9 PubMedCrossRefGoogle Scholar
  33. 33.
    Schwarz RE, Smith DD (2006) Extent of lymph node retrieval and pancreatic cancer survival: information from a large US population database. Ann Surg Oncol 13(9):1189–1200. doi:10.1245/s10434-006-9016-x PubMedCrossRefGoogle Scholar
  34. 34.
    Michalski CW, Kleeff J, Wente MN, Diener MK, Buchler MW, Friess H (2007) Systematic review and meta-analysis of standard and extended lymphadenectomy in pancreaticoduodenectomy for pancreatic cancer. Br J Surg 94(3):265–273. doi:10.1002/bjs.5716 PubMedCrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2013

Authors and Affiliations

  • H. A. Kanhere
    • 1
    • 2
  • M. I. Trochsler
    • 1
    • 2
  • M. H. Kanhere
    • 3
    • 4
  • A. N. Lord
    • 1
  • G. J. Maddern
    • 1
    • 2
  1. 1.Department of SurgeryThe Queen Elizabeth HospitalWoodville SouthAustralia
  2. 2.Division of SurgeryUniversity of AdelaideAdelaideAustralia
  3. 3.Department of Intensive Care MedicineLyell McEwin HospitalElizabeth ValeAustralia
  4. 4.Division of Acute Care MedicineUniversity of AdelaideAdelaideAustralia

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