Journal of Gastrointestinal Surgery

, Volume 16, Issue 3, pp 518–523 | Cite as

Effect of Surgeon Volume on Outcome Following Pancreaticoduodenectomy in a High-Volume Hospital

  • Nicolò Pecorelli
  • Gianpaolo Balzano
  • Giovanni Capretti
  • Alessandro Zerbi
  • Valerio Di Carlo
  • Marco BragaEmail author
Original Article



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.


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).


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.


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.


Pancreas Hospital volume Surgeon volume Pancreaticoduodenectomy Pancreatic fistula Postoperative morbidity 


  1. 1.
    Cameron JL, Riall TS, Coleman J, Belcher KA. One thousand consecutive pancreaticoduodenectomies. Ann Surg 2006; 244:10–15.PubMedCrossRefGoogle Scholar
  2. 2.
    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.PubMedCrossRefGoogle Scholar
  3. 3.
    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.PubMedCrossRefGoogle Scholar
  4. 4.
    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.PubMedCrossRefGoogle Scholar
  5. 5.
    Ho V, Heslin MJ. Effect of hospital volume and experience on in-hospital mortality for pancreaticoduodenectomy. Ann Surg 2003; 237: 509–514.PubMedGoogle 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: 786–795.PubMedCrossRefGoogle Scholar
  7. 7.
    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.PubMedCrossRefGoogle Scholar
  8. 8.
    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; 138:1310–1314PubMedCrossRefGoogle Scholar
  9. 9.
    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.PubMedCrossRefGoogle Scholar
  10. 10.
    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.PubMedCrossRefGoogle Scholar
  11. 11.
    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.PubMedCrossRefGoogle Scholar
  12. 12.
    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.PubMedCrossRefGoogle Scholar
  13. 13.
    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.PubMedCrossRefGoogle Scholar
  14. 14.
    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.PubMedCrossRefGoogle Scholar
  15. 15.
    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.PubMedCrossRefGoogle Scholar
  16. 16.
    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.Google 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; 240:205–213PubMedCrossRefGoogle Scholar
  18. 18.
    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; 244:931–937PubMedCrossRefGoogle Scholar
  19. 19.
    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.PubMedCrossRefGoogle Scholar
  20. 20.
    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.PubMedCrossRefGoogle Scholar
  21. 21.
    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.PubMedCrossRefGoogle Scholar
  22. 22.
    Eppsteiner RW, Csikesz NG, McPhee JT, Tseng JF, Shah SA. Surgeon volume impacts hospital mortality for pancreatic resection. Ann Surg 2009; 249: 635–640.PubMedCrossRefGoogle Scholar
  23. 23.
    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.PubMedCrossRefGoogle Scholar
  24. 24.
    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; 10:1280–1290PubMedCrossRefGoogle Scholar
  25. 25.
    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; 245:443–451PubMedCrossRefGoogle Scholar
  26. 26.
    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.PubMedCrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2011

Authors and Affiliations

  • Nicolò Pecorelli
    • 1
  • Gianpaolo Balzano
    • 1
  • Giovanni Capretti
    • 1
  • Alessandro Zerbi
    • 1
  • Valerio Di Carlo
    • 1
  • Marco Braga
    • 1
    Email author
  1. 1.Department of Surgery, San Raffaele HospitalVita-Salute San Raffaele UniversityMilanItaly

Personalised recommendations