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The Impact of Surgeon Volume on Outcomes After Pancreaticoduodenectomy: a Meta-analysis

  • Review Article
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background

Despite significant improvement in operative mortality rates following pancreaticoduodenectomy (PD), morbidity remains high. Outcomes following PD may be improved in high-volume centers and with high-volume surgeons. We sought to evaluate the association between surgeon experience and postoperative outcomes after PD.

Methods

An online database search of MEDLINE and EMBASE was performed; key bibliographies were reviewed. Studies comparing operative outcomes of high-volume surgeon (HVS) and low-volume surgeon (LVS) performing PD were included. Odds ratios with the corresponding 95% confidence intervals (CI) by random fixed effects models of pooled data were calculated. Definition of HVS varied among the studies, ranging from 6 to >20 PD/year. The primary endpoint was 30-day mortality, and secondary outcomes were complication rates, length of stay (LOS), hospital costs, and readmission rates. Study quality was assessed using STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) criteria.

Results

Search strategy yielded 360 publications. Eleven studies met the inclusion criteria comprising 36,449 patients. Among these patients, 12,512 (34.3%) PDs were performed by HVS and 23,937 (65.7%) by LVS. Meta-analysis of included studies showed that HVS had significantly lower mortality rates than LVS (2.4 vs. 6.7%, OR 2.88; 95% CI 2.51–3.27, p < 0.001). They also had significantly lower overall complication rates (36.3 vs. 50.3%, OR 1.71; 95% CI 1.62–1.81, p < 0.001), hospital costs (range $10,818–141,322 vs. $12,114–198,678, OR 0.13; 95% CI 0.07–0.19, p < 0.001), and LOS (range 11–35 vs. 14–38 days, OR 2.86; 95% CI 2.03–3.68, p < 0.001).

Conclusions

HVS performing PD have significantly better outcomes than LVS in terms of decreased mortality, morbidity, LOS, and hospital costs. Efforts toward increased regionalization of care should be discussed. Consensus regarding definition of HVS needs to be undertaken.

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References

  1. 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: 1128–37.

    Article  PubMed  Google Scholar 

  2. 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; 349:2117–27.

    Article  CAS  PubMed  Google Scholar 

  3. Ho V, Heslin M. Effect of hospital volume and experience on in-hospital mortality for pancreaticoduodenectomy. Ann Surg 2003; 237:509–14

    PubMed  PubMed Central  Google Scholar 

  4. Riediger H, Adam U, Utzolino S, Neeff HP, Hopt UT, Makowiec F. Perioperative outcome after pancreatic head resection: a 10-year series of specialized surgeons in a university hospital and a community hospital. J Gastrointest Surg 2014; 18: 1434–40.

    Article  PubMed  Google Scholar 

  5. Toomey PG, Teta AF, Patel KD, Ross SB, Rosemurgy AS. High-volume surgeons vs high-volume hospitals: are best outcomes more due to who or where? Am J Surg 2016; 211(1):59–63.

    Article  PubMed  Google Scholar 

  6. Hyder P, Dodson RM, Nathan H, Schneider EB, Weiss MJ, Cameron JL, Choti MA, Makary MA, Hirose K, Wolfgang CL, Herman JM, Pawlik TM. Influence of patient, physician, and hospital factors on 30-day readmission following pancreatoduodenectomy in the United States. JAMA Surg 2013; 148(12):1095–1102.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Schell MT, Barcia A, Spitzer AL, Harris SW. Pancreaticoduodenectomy: volume is not associated with outcomes with an academic health care system. HPB Surg 2008; 2008:825940

    Article  PubMed  PubMed Central  Google Scholar 

  8. Cunningham JD, O’Donnell N, Starker P. 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 2009; 198:227–30.

    Article  PubMed  Google Scholar 

  9. Moher D, Liberati A, Tetzlaff J, Altman DG, Prisma Group. Preferred reporting items for systematic reviews and meta-analyses: the Prisma Statement. PLoS Med 2009; 6(7):1–6.

    Article  Google Scholar 

  10. Diener MK, Knaebel HP, Heukaufer C, Antes G, Büchler MW, Seiler CM. A systematic review and meta-analysis of pylorus-preserving versus classical pancreaticoduodenectomy for surgical treatment of periampullary and pancreatic carcinoma. Ann Surg 2007; 245(2):187–200.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Vandenbroucke JP, von Elm E, Altman DG, Gotzsche PC, Mulrow CD, Pocock SJ, Poole C, Schlesselman JJ, Egger M. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration. PLoS Med 2007; 4(10):e297.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Mantel N, Haenszel W. Statistical aspects of the analysis of data from retrospective studies of disease. J Natl Cancer Inst. 1959; 22:719–48.

    CAS  PubMed  Google Scholar 

  13. Der Simonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials 1986; 7:177–88.

    Article  Google Scholar 

  14. Cheng Q, Zhang B, Zhang Y, Jiang X, Zhang B, Yi B, Luo X, Wu M. Predictive factors for complications after pancreaticoduodenectomy. J Surg Res 2007; 139:22–29.

    Article  PubMed  Google Scholar 

  15. Kakizawa N, Noda H, Watanabe F, Kamiyama H, Kato T, Ichida K, Rikiyama T. Instruction of expert surgeon secures favorable outcomes after standard pancreaticoduodenectomy performed by less experienced surgeons. Hepatogastroenterology 2014; 61:203–7.

    PubMed  Google Scholar 

  16. 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.

    Article  CAS  PubMed  Google Scholar 

  17. 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(7): 634–40.

    Article  PubMed  Google Scholar 

  18. Pecorelli N, Balzano G, Capretti G, Capretti G, Zerbi A, Di Carlo V, Braga M. Effect of surgeon volume on outcome following pancreaticoduodenectomy in a high-volume hospital. J Gastrointest Surg 2012; 16:518–23.

    Article  PubMed  Google Scholar 

  19. Mathur A, Luberice K, Ross, S, Choung E, Rosemurgy A. Pancreaticoduodenectomy at high-volume centers: Surgeon volume goes beyond the leapfrog criteria. Ann Surg 2015; 262(2):37–39.

    Article  Google Scholar 

  20. 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; 12:442–9

    Article  PubMed  Google Scholar 

  21. Schneider EB, Hyder O, Wolfgang CL, Dodson RM, Haider AH, Herman JM, Pawlik TM. Provider versus patient factors impacting hospital length of stay after pancreaticoduodenectomy. Surgery 2013; 154:152–61.

    Article  PubMed  Google Scholar 

  22. Kennedy TJ, Cassera MA, Wolf R, Swanstrom LL, Hansen PD. Surgeon volume versus morbidity and cost in patients undergoing pancreaticoduodenectomy in an academic community medical center. J Gastrointest Surg 2010; 14:1990–6.

    Article  PubMed  Google Scholar 

  23. Shi HY, Wang SN, Lee KT. Temporal trends and volume-outcome associations in periampullary cancer patients: a propensity score-adjusted nationwide population-based study. Am J Surg 2014; 207:512–19.

    Article  PubMed  Google Scholar 

  24. 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.

    Article  CAS  PubMed  Google Scholar 

  25. 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 factor and the impact of hospital volume. Ann Surg 2000; 232(6):786–95.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  26. Hata T, Motoi F, Ishida M, Naitoh T, Katayose Y, Egawa S, Unno M. Effect of hospital volume on surgical outcomes after pancreaticoduodenectomy. A systematic review and meta-analysis. Ann Surg 2016; 263(4):664–72.

    Article  PubMed  Google Scholar 

  27. 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; 208:528–38.

    Article  PubMed  Google Scholar 

  28. Tamijmarane A, Bhati CS, Mirza DF, Bramhall SR, Mayer SR, Wigmore SJ, Buckels JA. Application of Portsmouth modification of physiological and operative severity scoring system for enumeration of morbidity and mortality (P-POSSUM) in pancreatic surgery. World J Surg Oncol 2008; 6:39.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Schneider EV, Hyder O, Wolfgang CL, Hirose K, Choti MA, Makary MA, Herman JM, Cameron JL, Pawlik TM. Patient readmission and mortality after surgery for hepato-pancreato-biliary malignancies. J Am Coll Surg 2012; 215:607–15.

    Article  PubMed  PubMed Central  Google Scholar 

  30. 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.

    Article  PubMed  Google Scholar 

  31. Nathan H, Pawlik TM. Limitations of claims and registry data in surgical oncology research. Ann Surg Onc 2008; 15: 415–23.

    Article  Google Scholar 

  32. Mehta HB, Parmar AD, Adhikari D, Tamirisa NP, Dimou F, Jupiter D, Riall TS. Relative impact of surgeon and hospital volume on operative mortality and complications following pancreatic resection in Medicare patients. J Surg Res 2016; 204:326–34.

    Article  PubMed  PubMed Central  Google Scholar 

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Authors and Affiliations

  1. Department of Surgery, Providence Hospital and Medical Centers, Michigan State University College of Human Medicine, 16001 W Nine Mile Rd, Southfield, MI, 48075, USA

    Francisco Igor B. Macedo, Prakash Jayanthi & Mia Mowzoon

  2. Division of Surgical Oncology, Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, USA

    Danny Yakoub, Vikas Dudeja & Nipun Merchant

Authors
  1. Francisco Igor B. Macedo
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  2. Prakash Jayanthi
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  3. Mia Mowzoon
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  4. Danny Yakoub
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  5. Vikas Dudeja
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  6. Nipun Merchant
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Contributions

Study conception and design was done by Macedo, Jayanthi, and Merchant. Acquisition of data was done by Macedo, Jayanthi, Mowzoon, and Yakoub. Interpretation of data was done by Macedo, Jayanthi, Mowzoon, Yakoub, Dudeja, and Merchant. Drafting of the manuscript was done by Macedo, Jayanthi, Mowzoon, Yakoub, and Merchant. Critical revision was done by Macedo, Yakoub, Dudeja, and Merchant. Final approval was done by Macedo, Jayanthi, Mowzoon, Yakoub, Dudeja, and Merchant. Agreement to be accountable for all aspects of work was done by Macedo, Jayanthi, Mowzoon, Yakoub, Dudeja, and Merchant.

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Correspondence to Francisco Igor B. Macedo.

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Macedo, F.I.B., Jayanthi, P., Mowzoon, M. et al. The Impact of Surgeon Volume on Outcomes After Pancreaticoduodenectomy: a Meta-analysis. J Gastrointest Surg 21, 1723–1731 (2017). https://doi.org/10.1007/s11605-017-3498-7

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  • DOI: https://doi.org/10.1007/s11605-017-3498-7

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