Journal of Gastrointestinal Surgery

, Volume 14, Issue 12, pp 1990–1996 | Cite as

Surgeon Volume Versus Morbidity and Cost in Patients Undergoing Pancreaticoduodenectomy in an Academic Community Medical Center

  • Timothy J. Kennedy
  • Maria A. Cassera
  • Ronald Wolf
  • Lee L. Swanstrom
  • Paul D. Hansen
Original Article



Despite trends toward regionalization of care, the majority of pancreaticoduodenectomies (PD) are performed in community hospitals by surgeons with varying degrees of experience. We analyzed the impact of several variables, including surgeon volume, on outcomes following PD within a high-volume community-based teaching hospital system.


Patients who underwent PD from 2005 to 2008 were reviewed retrospectively. Perioperative data, complications, and hospital financial data was queried. A high-volume (HV) surgeon was defined as an average of 10 or more PD per year.


Ninety-four patients underwent PD with an overall operative mortality rate of 9.6% (HV 2.2%, LV 16.0%), major complication rate of 32% (HV 18%, LV 44%), and median cost of $30,860 (HV $27,185, LV $33,007). Factors predictive of death were age (p < 0.02), body mass index (p < 0.01), and surgeon volume (p < 0.05). Factors predictive of major complication were surgeon volume (p < 0.01) and body mass index (p < 0.01). Factors predictive for increased length of stay for patients discharged from the hospital were surgeon volume (p < 0.02) and preoperative ASA classification (p < 0.05).


Surgeon volume and patient body mass index have a significant impact on perioperative morbidity following PD in a community teaching hospital.


Pancreaticoduodenectomy Cost analysis Surgical morbidity Surgeon volume 


  1. 1.
    Begg CB, Cramer LD, Hoskins WJ, Brennan MF. Impact of hospital volume on operative mortality for major cancer surgery. JAMA 1998; 280(20):1747–51.CrossRefPubMedGoogle Scholar
  2. 2.
    Birkmeyer JD, Finlayson SR, Tosteson AN, Sharp SM, Warshaw AL, Fisher ES. Effect of hospital volume on in-hospital mortality with pancreaticoduodenectomy. Surgery 1999; 125(3):250–6.PubMedGoogle Scholar
  3. 3.
    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(15):1128–37.CrossRefPubMedGoogle Scholar
  4. 4.
    Glasgow RE, Mulvihill SJ. Hospital volume influences outcome in patients undergoing pancreatic resection for cancer. West J Med 1996; 165(5):294–300.PubMedGoogle Scholar
  5. 5.
    Gordon TA, Bowman HM, Bass EB, Lillemoe KD, Yeo CJ, Heitmiller RF, Choti MA, Burleyson GP, Hsieh G, Cameron JL. Complex gastrointestinal surgery: impact of provider experience on clinical and economic outcomes. J Am Coll Surg 1999; 189(1):46–56.CrossRefPubMedGoogle Scholar
  6. 6.
    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(6):786–95.CrossRefPubMedGoogle Scholar
  7. 7.
    Sosa JA, Bowman HM, Gordon TA, Bass EB, Yeo CJ, Lillemoe KD, Pitt HA, Tielsch JM, Cameron JL. Importance of hospital volume in the overall management of pancreatic cancer. Ann Surg 1998; 228(3):429–38.CrossRefPubMedGoogle Scholar
  8. 8.
    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(22):2117–27.CrossRefPubMedGoogle Scholar
  9. 9.
    Eppsteiner RW, Csikesz NG, McPhee JT, Tseng JF, Shah SA. Surgeon volume impacts hospital mortality for pancreatic resection. Ann Surg 2009; 249(4):635–40.CrossRefPubMedGoogle Scholar
  10. 10.
    Garnick DW, Luft HS, McPhee SJ, Mark DH. Surgeon volume vs hospital volume: which matters more? JAMA 1989; 262(4):547–8.CrossRefPubMedGoogle Scholar
  11. 11.
    Ho V, Aloia T. Hospital volume, surgeon volume, and patient costs for cancer surgery. Med Care 2008; 46(7):718–25.CrossRefPubMedGoogle Scholar
  12. 12.
    Rosemurgy A, Cowgill S, Coe B, Thomas A, Al-Saadi S, Goldin S, Zervos E. Frequency with which surgeons undertake pancreaticoduodenectomy continues to determine length of stay, hospital charges, and in-hospital mortality. J Gastrointest Surg 2008; 12(3):442–9.CrossRefPubMedGoogle Scholar
  13. 13.
    McPhee JT, Hill JS, Whalen GF, Zayaruzny M, Litwin DE, Sullivan ME, Anderson FA, Tseng JF. Perioperative mortality for pancreatectomy: a national perspective. Ann Surg 2007; 246(2):246–53.CrossRefPubMedGoogle Scholar
  14. 14.
    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(6):781–8, discussion 788–90.CrossRefPubMedGoogle Scholar
  15. 15.
    Ho V, Heslin MJ. Effect of hospital volume and experience on in-hospital mortality for pancreaticoduodenectomy. Ann Surg 2003; 237(4):509–14.CrossRefPubMedGoogle Scholar
  16. 16.
    Meguid RA, Ahuja N, Chang DC. What constitutes a "high-volume" hospital for pancreatic resection? J Am Coll Surg 2008; 206(4):622 e1–9.CrossRefPubMedGoogle Scholar
  17. 17.
    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(2):205–13.CrossRefPubMedGoogle Scholar
  18. 18.
    Martin RC, 2nd, Brennan MF, Jaques DP. Quality of complication reporting in the surgical literature. Ann Surg 2002; 235(6):803–13.CrossRefPubMedGoogle Scholar
  19. 19.
    Birkmeyer JD. Relation of surgical volume to outcome. Ann Surg 2000; 232(5):724–5.CrossRefPubMedGoogle Scholar
  20. 20.
    Luft HS, Bunker JP, Enthoven AC. Should operations be regionalized? The empirical relation between surgical volume and mortality. N Engl J Med 1979; 301(25):1364–9.CrossRefPubMedGoogle Scholar
  21. 21.
    Cooperman AM, Schwartz ET, Fader A, Golier F, Feld M. Safety, efficacy, and cost of pancreaticoduodenal resection in a specialized center based at a community hospital. Arch Surg 1997; 132(7):744–7; Discussion 748.PubMedGoogle Scholar
  22. 22.
    Schell MT, Barcia A, Spitzer AL, Harris HW. Pancreaticoduodenectomy: volume is not associated with outcome within an academic health care system. HPB Surg 2008; 2008:825940.CrossRefPubMedGoogle Scholar
  23. 23.
    Afsari A, Zhandoug Z, Young S, Ferguson L, Silapaswan S, Mittal V. Outcome analysis of pancreaticoduodenectomy at a community hospital. Am Surg 2002; 68(3):281–4; discussion 284–5.PubMedGoogle Scholar
  24. 24.
    Cunningham JD, O'Donnell N, Starker P (2009) Surgical outcomes following pancreatic resection at a low-volume community hospital: do all patients need to be sent to a regional cancer center? Am J Surg 198:227–30CrossRefPubMedGoogle Scholar
  25. 25.
    Guzzo MH, Landercasper J, Boyd WC, Lambert PJ. Outcomes of complex gastrointestinal procedures performed in a community hospital. WMJ 2005; 104(6):30–4.PubMedGoogle Scholar
  26. 26.
    Houghton A. Variation in outcome of surgical procedures. Br J Surg 1994; 81(5):653–60.CrossRefPubMedGoogle Scholar
  27. 27.
    Riall TS, Nealon WH, Goodwin JS, Townsend CM, Freeman JL. Outcomes following pancreatic resection: variability among high-volume providers. Surgery 2008; 144(2):133–40.CrossRefPubMedGoogle Scholar
  28. 28.
    Wade TP, Johnson FE. "Practice makes perfect" is intuitive; the applicability of this axiom to surgical outcomes has been tenuous at best. Ann Surg 1996; 223(4):446–7.CrossRefPubMedGoogle Scholar
  29. 29.
    Metreveli RE, Sahm K, Abdel-Misih R, Petrelli NJ. Major pancreatic resections for suspected cancer in a community-based teaching hospital: lessons learned. J Surg Oncol 2007; 95(3):201–6.CrossRefPubMedGoogle Scholar
  30. 30.
    Rosemurgy AS, Bloomston M, Serafini FM, Coon B, Murr MM, Carey LC. Frequency with which surgeons undertake pancreaticoduodenectomy determines length of stay, hospital charges, and in-hospital mortality. J Gastrointest Surg 2001; 5(1):21–6.CrossRefPubMedGoogle Scholar
  31. 31.
    Vanounou T, Pratt W, Fischer JE, Vollmer CM, Callery MP. Deviation-based cost modeling: a novel model to evaluate the clinical and economic impact of clinical pathways. J Am Coll Surg 2007; 204(4):570–9.CrossRefPubMedGoogle Scholar
  32. 32.
    Porter GA, Pisters PW, Mansyur C, Bisanz A, Reyna K, Stanford P, Lee JE, Evans DB. Cost and utilization impact of a clinical pathway for patients undergoing pancreaticoduodenectomy. Ann Surg Oncol 2000; 7(7):484–9.CrossRefPubMedGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2010

Authors and Affiliations

  • Timothy J. Kennedy
    • 1
  • Maria A. Cassera
    • 1
    • 2
  • Ronald Wolf
    • 1
    • 3
  • Lee L. Swanstrom
    • 2
  • Paul D. Hansen
    • 1
    • 2
    • 4
  1. 1.Hepatobiliary and Pancreatic Surgery ProgramProvidence Portland Medical CenterPortlandUSA
  2. 2.Gastrointestinal and Minimally Invasive Surgery DivisionThe Oregon ClinicPortlandUSA
  3. 3.Westside Surgical DivisionThe Oregon ClinicPortlandUSA
  4. 4.Department of SurgeryProvidence Medical CenterPortlandUSA

Personalised recommendations