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Cawich SO, Shukla PJ, Shrikhande SV, Dixon E, Pearce NW, Deshpande R, Francis W. Time to retire the term "high volume" and replace with "high quality" for HPB centers: A position statement from Caribbean chapter of AHPBA. Surgeon 2024; 22:e117-e119. [PMID: 38135631 DOI: 10.1016/j.surge.2023.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 11/29/2023] [Indexed: 12/24/2023]
Affiliation(s)
- Shamir O Cawich
- University of the West Indies, St Augustine, Trinidad & Tobago, West Indies.
| | - Parul J Shukla
- Northwell Health, Professor of Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
| | | | | | - Neil W Pearce
- Southampton University Hospital NHS Trust, Southampton, United Kingdom
| | - Rahul Deshpande
- Manchester Royal Infirmary and Christie Hospital, Manchester, UK
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Parina R, Emamaullee J, Ahmed S, Kaur N, Genyk Y, Raashid Sheikh M. Impact of Medicaid Expansion on Surgical Care and Outcomes for Hepatobiliary Malignancies. Am Surg 2024; 90:829-839. [PMID: 37955410 DOI: 10.1177/00031348231216492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
BACKGROUND As part of the Patient Protection and Affordable Care Act, some states expanded Medicaid eligibility to adults with incomes below 138% of the federal poverty line. While this resulted in an increased proportion of insured residents, its impact on the diagnosis and treatment of hepatopancreaticobiliary (HPB) cancers has not been studied. STUDY DESIGN The National Cancer Database (NCDB) from 2010 to 2017 was used. Patients diagnosed with HPB malignancies in states which expanded in 2014 were compared to patients in non-expansion states. Subset analyses of patients who underwent surgery and those in high-risk socioeconomic groups were performed. Outcomes studied included initiation of treatment within 30 days of diagnosis, stage at diagnosis, care at high volume or academic center, perioperative outcomes, and overall survival. Adjusted difference-in-differences analysis was performed. RESULTS A total of 345,684 patients were included, of whom 55% resided in non-expansion states and 54% were diagnosed with pancreatic cancer. Overall survival was higher in states with Medicaid expansion (HR .90, 95% CI [.88-.92], P < .01). There were also better postoperative outcomes including 30-day mortality (.67 [.57-.80], P < .01) and 30-day readmissions (.87 [.78-.97], P = .02) as well as increased likelihood of having surgery in a high-volume center (1.42 [1.32-1.53], P < .01). However, there were lower odds of initiating care within 30 days of diagnosis (.77 [.75-.80], P < .01) and higher likelihood of diagnosis with stage IV disease (1.09 [1.06-1.12], P < .01) in expansion states. CONCLUSION While operative outcomes and overall survival from HPB cancers were better in states with Medicaid expansion, there was no improvement in timeliness of initiating care or stage at diagnosis.
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Affiliation(s)
- Ralitza Parina
- Department of Surgery, Keck Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Juliet Emamaullee
- Department of Surgery, Keck Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Saif Ahmed
- Department of Surgery, Keck Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Navpreet Kaur
- Department of Surgery, Keck Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Yuri Genyk
- Department of Surgery, Keck Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Mohd Raashid Sheikh
- Department of Surgery, Keck Medical Center, University of Southern California, Los Angeles, CA, USA
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Cawich SO, Dixon E, Shukla PJ, Shrikhande SV, Deshpande RR, Mohammed F, Pearce NW, Francis W, Johnson S, Bujhawan J. Rescue from complications after pancreaticoduodenectomies at a low-volume Caribbean center: Value of tailored peri-pancreatectomy protocols. World J Gastrointest Surg 2024; 16:681-688. [PMID: 38577074 PMCID: PMC10989354 DOI: 10.4240/wjgs.v16.i3.681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/03/2024] [Accepted: 01/27/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) is a technically complex operation, with a relatively high risk for complications. The ability to rescue patients from post-PD complications is as a recognized quality measure. Tailored protocols were instituted at our low volume facility in the year 2013. AIM To document the rate of rescue from post-PD complications with tailored protocols in place as a measure of quality. METHODS A retrospective audit was performed to collect data from patients who experienced major post-PD complications at a low volume pancreatic surgery unit in Trinidad and Tobago between January 1, 2013 and June 30, 2023. Standardized definitions from the International Study Group of Pancreatic Surgery were used to define post-PD complications, and the modified Clavien-Dindo classification was used to classify post-PD complications. RESULTS Over the study period, 113 patients at a mean age of 57.5 years (standard deviation [SD] ± 9.23; range: 30-90; median: 56) underwent PDs at this facility. Major complications were recorded in 33 (29.2%) patients at a mean age of 53.8 years (SD: ± 7.9). Twenty-nine (87.9%) patients who experienced major morbidity were salvaged after aggressive treatment of their complication. Four (3.5%) died from bleeding pseudoaneurysm (1), septic shock secondary to a bile leak (1), anastomotic leak (1), and myocardial infarction (1). There was a significantly greater salvage rate in patients with American Society of Anesthesiologists scores ≤ 2 (93.3% vs 25%; P = 0.0024). CONCLUSION This paper adds to the growing body of evidence that volume alone should not be used as a marker of quality for patients requiring PD. Despite low volumes at our facility, we demonstrated that 87.9% of patients were rescued from major complications. We attributed this to several factors including development of rescue protocols, the competence of the pancreatic surgery teams and continuous, and adaptive learning by the entire institution, culminating in the development of tailored peri-pancreatectomy protocols.
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Affiliation(s)
- Shamir O Cawich
- Department of Surgery, University of the West Indies, St Augustine 000000, Trinidad and Tobago
| | - Elijah Dixon
- Department of Surgery, Faculty of Medicine, University of Calgary, Calgary, Alberta T2N2T9, Canada
| | - Parul J Shukla
- Department of Surgery, Weill Cornell Medical College, New York, NY 10065, United States
| | - Shailesh V Shrikhande
- Department of Surgical Oncology, Tata Memorial Center, Homi Bhabha National University, Mumbai 400012, India
| | - Rahul R Deshpande
- Department of Surgery, Manchester Royal Infirmary, Manchester M13 9WL, United Kingdom
| | - Fawwaz Mohammed
- Department of Surgery, University of the West Indies, St Augustine 000000, Trinidad and Tobago
| | - Neil W Pearce
- University Surgical Unit, Southampton General Hospital, Southampton SO16 6YD, United Kingdom
| | - Wesley Francis
- Department of Surgery, University of the West Indies, Nassau N-1184, Bahamas
| | - Shaneeta Johnson
- Department of Surgery, Morehouse School of Medicine, Atlanta, GA 30310, United States
| | - Johann Bujhawan
- Department of Surgery, General Hospital in Port of Spain, Port of Spain 000000, Trinidad and Tobago
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Amin K, Khan H, Hearld LR, Chu DI, Prete V, Mehari KR, Heslin MJ, Fonseca AL. Association between Rural Residence and Processes of Care in Pancreatic Cancer Treatment. J Gastrointest Surg 2023; 27:2155-2165. [PMID: 37553515 PMCID: PMC10731615 DOI: 10.1007/s11605-023-05764-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 06/17/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND Pancreatic adenocarcinoma (PDAC) is an aggressive malignancy associated with poor outcomes. Surgical resection and receipt of multimodal therapy have been shown to improve outcomes in patients with potentially resectable PDAC; however treatment and outcome disparities persist on many fronts. The aim of this study was to analyze the relationship between rural residence and receipt of quality cancer care in patients diagnosed with non-metastatic PDAC. METHODS Using the National Cancer Database, patients with non-metastatic pancreatic cancer were identified from 2006-2016. Patients were classified as living in metropolitan, urban, or rural areas. Multivariable logistic regression was used to identify predictors of cancer treatment and survival. RESULTS A total of 41,786 patients were identified: 81.6% metropolitan, 16.2% urban, and 2.2% rural. Rural residing patients were less likely to receive curative-intent surgery (p = 0.037) and multimodal therapy (p < 0.001) compared to their metropolitan and urban counterparts. On logistic regression analysis, rural residence was independently associated with decreased surgical resection [OR 0.82; CI 95% 0.69-0.99; p = 0.039] and multimodal therapy [OR 0.70; CI 95% 0.38-0.97; p = 0.047]. Rural residence independently predicted decreased overall survival [OR 1.64; CI 95% 1.45-1.93; p < 0.001] for all patients that were analyzed. In the cohort of patients who underwent surgical resection, rural residence did not independently predict overall survival [OR 0.97; CI 95% 0.85-1.11; p = 0.652]. CONCLUSIONS Rural residence impacts receipt of optimal cancer care in patients with non-metastatic PDAC but does not predict overall survival in patients who receive curative-intent treatment.
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Affiliation(s)
- Krisha Amin
- Department of Surgery, The University of South Alabama, 2451 USA Medical Center Drive, Mastin, 705, Mobile, AL, 36617, USA
| | - Hamza Khan
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Larry R Hearld
- Department of Health Services Administration, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Daniel I Chu
- Department of Surgery, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Victoria Prete
- Department of Surgery, The University of South Alabama, 2451 USA Medical Center Drive, Mastin, 705, Mobile, AL, 36617, USA
| | - Krista R Mehari
- Department of Psychology, The University of South Alabama, Mobile, AL, USA
| | - Martin J Heslin
- Department of Surgery, The University of South Alabama, 2451 USA Medical Center Drive, Mastin, 705, Mobile, AL, 36617, USA
| | - Annabelle L Fonseca
- Department of Surgery, The University of South Alabama, 2451 USA Medical Center Drive, Mastin, 705, Mobile, AL, 36617, USA.
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Cawich SO, Cabral R, Douglas J, Thomas DA, Mohammed FZ, Naraynsingh V, Pearce NW. Whipple's procedure for pancreatic cancer: training and the hospital environment are more important than volume alone. SURGERY IN PRACTICE AND SCIENCE 2023; 14:100211. [PMID: 39845848 PMCID: PMC11749909 DOI: 10.1016/j.sipas.2023.100211] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/14/2023] [Accepted: 08/15/2023] [Indexed: 01/24/2025] Open
Abstract
Background In our center, patients with pancreatic cancer traditionally had Whipple's resections by general surgery teams until January 2013 when a hepatopancreatobiliary (HPB) was introduced. We compared outcomes before and after introduction of HPB teams. Methods Data were collected from the records of all patients booked for Whipple's resections over a 12-year period. The data were divided into two groups: Group A consisted of the 6-year period from January 1, 2007 to December 30, 2012 during which all resections were performed by GS teams. Group B comprised patients in the 6-year period from January 1, 2013 to December 30, 2019 during which operations were performed by HPB teams. All statistical analyses were carried out using SPSS ver 16.0 and a P Value <0.05 was considered statistically significant. Results The patients selected for Whipple's resections in Group A had statistically better performance status and lower anaesthetic risk. Despite this, patients in Group A had higher conversions to palliative operations (66% vs 5.3%), longer mean operating time (517±25 vs 367±54 min; P<0.0001), higher blood loss (3687±661 vs 1394±656 ml; P<0.0001), greater transfusion requirements (4.3±1.3 vs 1.9±1.4 units; P<0.001), greater likelihood of prolonged ICU stay (100% vs 40%; P=0.19), higher overall morbidity (75% vs 22.2%; P=0.02), higher major morbidity (75% vs 13.9%; P=0.013), more procedure-related complications (75% vs 9.7%; P=0.003) and higher mortality rates (75% vs 5.6%; P<0.0001). The HPB teams were more likely to perform vein resection and reconstruction to achieve clear margins (26.4% vs 0; P=0.57). Conclusion This paper adds to the growing body of evidence that volume alone should not be used as a marker of quality for patients requiring Whipple's procedures.
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Affiliation(s)
- Shamir O. Cawich
- Department of Clinical Surgical Sciences, University of the West Indies, St Augustine Campus, Trinidad & Tobago, West Indies
| | - Robyn Cabral
- Department of Clinical Surgical Sciences, University of the West Indies, St Augustine Campus, Trinidad & Tobago, West Indies
| | - Jacintha Douglas
- Department of Clinical Surgical Sciences, University of the West Indies, St Augustine Campus, Trinidad & Tobago, West Indies
| | - Dexter A. Thomas
- Department of Clinical Surgical Sciences, University of the West Indies, St Augustine Campus, Trinidad & Tobago, West Indies
| | - Fawwaz Z. Mohammed
- Department of Clinical Surgical Sciences, University of the West Indies, St Augustine Campus, Trinidad & Tobago, West Indies
| | - Vijay Naraynsingh
- Department of Clinical Surgical Sciences, University of the West Indies, St Augustine Campus, Trinidad & Tobago, West Indies
| | - Neil W. Pearce
- Department of Surgery, Southampton University NHS Trust, Southampton, United Kingdom SO16DP
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Heard J, Cronin L, Romanowski K, Greenhalgh D, Palmieri T, Sen S. Massive Burn Injuries: Characteristics and Outcomes From a Single Institution. J Burn Care Res 2023; 44:925-930. [PMID: 36378582 DOI: 10.1093/jbcr/irac173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
Massive burn injuries are a unique patient population with unique treatment paradigms. Data from 155 adult patients, admitted from 2009 to 2019, with >50% total body surface area burns (TBSA) were collected and analyzed. Average burn size was 70% TBSA and 63% had a concomitant inhalation injury. Approximately 30% of patients (46/155) transitioned to comfort care-only measures within 24 hours of admission. Standard treatment patients were younger (37 ± 13 vs 60 ± 19 years; p < .00001), male (94% vs 28%; p = .001) and had smaller TBSA (66 ± 13 vs 80 ± 16; p < .00001). Of the standard treatment group, 72 (66%) survived to discharge. Survivors had smaller TBSA (64 ± 13 vs 71 ± 13; p = .003), less third-degree TBSA (48 ± 25 vs 71 ± 13; p = .003) and lower incidence of renal failure requiring dialysis (22% vs 73%, p < .00001). Multivariate regression analysis showed that age (OR 1.05; p = .025), total TBSA (OR 1.07; p = .005), and renal failure (OR 10.2; p = .00005) were independently associated with mortality. Inhalation injury was not significantly associated with mortality. About 23% (35/155) of patients had a psychiatric condition on admission and 19% (30/155) of patients were burned attempting suicide. Patients with psychiatric conditions spent more time in the hospital (62 vs 30 days; p = .004), more time on ventilator (31 vs 12 days; p = .046), underwent more surgery (4 vs 2 operations, p = .03), and were less likely to die (34% vs 59%; p = .02). In summary, age, burn size, and renal failure were independently associated with mortality, with renal failure being the strongest factor. Psychiatric conditions are prevalent pre-injury and tend to require more inpatient care.
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Affiliation(s)
- J Heard
- Burn Division, Department of Surgery University of California Davis, Sacramento, California, USA
| | - Laura Cronin
- Burn Division, Department of Surgery University of California Davis, Sacramento, California, USA
| | - K Romanowski
- Burn Division, Department of Surgery University of California Davis, Sacramento, California, USA
| | - D Greenhalgh
- Burn Division, Department of Surgery University of California Davis, Sacramento, California, USA
| | - T Palmieri
- Burn Division, Department of Surgery University of California Davis, Sacramento, California, USA
| | - S Sen
- Burn Division, Department of Surgery University of California Davis, Sacramento, California, USA
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Khan H, Cherla D, Mehari K, Tripathi M, Butler TW, Crook ED, Heslin MJ, Johnston FM, Fonseca AL. Palliative Therapies in Metastatic Pancreatic Cancer: Does Medicaid Expansion Make a Difference? Ann Surg Oncol 2023; 30:179-188. [PMID: 36169753 PMCID: PMC11539046 DOI: 10.1245/s10434-022-12563-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 08/28/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the impact of medicaid expansion (ME) on receipt of palliative therapies in metastatic pancreatic cancer patients. PATIENTS AND METHODS A difference-in-differences (DID) approach was used to analyze patients with metastatic pancreatic cancer identified from the National Cancer Database diagnosed during two time periods: pre-expansion (2010-2012) and post-expansion (2014-2016). Patients diagnosed while residing in ME states were compared with those in non-ME states. Multivariable logistic regression was used to identify predictors of receipt of palliative therapies. RESULTS Of 87,738 patients overall, 7483(18.1%) received palliative therapies in the pre-expansion, while 10,211(21.5%) received palliative therapies in the post-expansion period. In the pre-expansion period, treatment at a high-volume facility (HVF) (odds ratio [OR] 1.10, 95% confidence interval [CI] 1.02-1.18) and non-west geographic location were predictive of increased palliative therapies. In the post-expansion period, treatment at an HVF (OR 1.09, 95% CI 1.02-1.16), geographic location, and living in an ME state at the time of diagnosis (OR 1.14, 95% CI 1.06-1.22) were predictive of increased palliative therapies. Older age, highest quartile median income (zip-code based), and treatment at a nonacademic facility were independently associated with decreased palliative therapies in both periods. DID analysis demonstrated that patients with metastatic pancreatic cancer living in ME states had increased receipt of palliative therapies relative to those in non-ME states (DID = 2.68, p < 0.001). CONCLUSIONS The overall utilization of palliative therapies in metastatic pancreatic cancer is low. Multiple sociodemographic disparities exist in the receipt of palliative therapies. ME is associated with increased receipt of palliative therapies in patients with metastatic pancreatic cancer.
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Affiliation(s)
- Hamza Khan
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Deepa Cherla
- Department of Surgery, The University of South Alabama, Mobile, AL, USA
| | - Krista Mehari
- Department of Psychology, The University of South Alabama, Mobile, AL, USA
| | - Manish Tripathi
- Kellogg School of Management, Northwestern University, Chicago, IL, USA
| | - Thomas W Butler
- Department of Internal Medicine, The University of South Alabama, Mobile, AL, USA
| | - Errol D Crook
- Department of Internal Medicine, The University of South Alabama, Mobile, AL, USA
| | - Martin J Heslin
- Department of Surgery, The University of South Alabama, Mobile, AL, USA
| | - Fabian M Johnston
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Cawich SO, Thomas DA, Pearce NW, Naraynsingh V. Whipple’s pancreaticoduodenectomy at a resource-poor, low-volume center in Trinidad and Tobago. World J Clin Oncol 2022; 13:738-747. [PMID: 36212600 PMCID: PMC9537505 DOI: 10.5306/wjco.v13.i9.738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/22/2022] [Accepted: 08/17/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Many authorities advocate for Whipple’s procedures to be performed in high-volume centers, but many patients in poor developing nations cannot access these centers. We sought to determine whether clinical outcomes were acceptable when Whipple’s procedures were performed in a low-volume, resource-poor setting in the West Indies.
AIM To study outcomes of Whipple’s procedures in a pancreatic unit in the West Indies over an eight-year period from June 1, 2013 to June 30, 2021.
METHODS This was a retrospective study of all patients undergoing Whipple’s procedures in a pancreatic unit in the West Indies over an eight-year period from June 1, 2013 to June 30, 2021.
RESULTS This center performed an average of 11.25 procedures per annum. There were 72 patients in the final study population at a mean age of 60.2 years, with 52.7% having American Society of Anesthesiologists scores ≥ III and 54.1% with Eastern Cooperative Oncology Group scores ≥ 2. Open Whipple’s procedures were performed in 70 patients and laparoscopic assisted procedures in 2. Portal vein resection/reconstruction was performed in 19 (26.4%) patients. In patients undergoing open procedures there was 367 ± 54.1 min mean operating time, 1394 ± 656.8 mL mean blood loss, 5.24 ± 7.22 d mean intensive care unit stay and 15.1 ± 9.53 d hospitalization. Six (8.3%) patients experienced minor morbidity, 10 (14%) major morbidity and there were 4 (5.5%) deaths.
CONCLUSION This paper adds to the growing body of evidence that volume alone should not be used as a marker of quality for patients requiring Whipple’s procedures. Low volume centers in resource poor nations can achieve good short-term outcomes. This is largely due to the process of continuous, adaptive learning by the entire hospital.
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Affiliation(s)
- Shamir O Cawich
- Department of Surgery, Port of Spain General Hospital, Port of Spain 000000, Trinidad and Tobago
| | - Dexter A Thomas
- Department of Surgery, Port of Spain General Hospital, Port of Spain 000000, Trinidad and Tobago
| | - Neil W Pearce
- Department of Surgery, Southampton General Hospital National Health Services Trust, Southampton SO16 6YD, United Kingdom
| | - Vijay Naraynsingh
- Department of Surgery, Port of Spain General Hospital, Port of Spain 000000, Trinidad and Tobago
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Cawich SO, Pearce NW, Naraynsingh V, Shukla P, Deshpande RR. Whipple’s operation with a modified centralization concept: A model in low-volume Caribbean centers. World J Clin Cases 2022; 10:7620-7630. [PMID: 36158490 PMCID: PMC9372853 DOI: 10.12998/wjcc.v10.i22.7620] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 05/05/2022] [Accepted: 06/26/2022] [Indexed: 02/06/2023] Open
Abstract
Conventional data suggest that complex operations, such as a pancreaticoduodenectomy (PD), should be limited to high volume centers. However, this is not practical in small, resource-poor countries in the Caribbean. In these settings, patients have no option but to have their PDs performed locally at low volumes, occasionally by general surgeons. In this paper, we review the evolution of the concept of the high-volume center and discuss the feasibility of applying this concept to low and middle-income nations. Specifically, we discuss a modification of this concept that may be considered when incorporating PD into low-volume and resource-poor countries, such as those in the Caribbean. This paper has two parts. First, we performed a literature review evaluating studies published on outcomes after PD in high volume centers. The data in the Caribbean is then examined and we discuss the incorporation of this operation into resource-poor hospitals with modifications of the centralization concept. In the authors’ opinions, most patients who require PD in the Caribbean do not have realistic opportunities to have surgery in high-volume centers in developed countries. In these settings, their only options are to have their operations in the resource-poor, low-volume settings in the Caribbean. However, post-operative outcomes may be improved, despite low-volumes, if a modified centralization concept is encouraged.
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Affiliation(s)
- Shamir O Cawich
- Department of Clinical Surgical Sciences, University of the West Indies, St Augustine 000000, Trinidad and Tobago
| | - Neil W Pearce
- University Surgical Unit, Southampton General Hospital, Southampton SO16 6YD, United Kingdom
| | - Vijay Naraynsingh
- Department of Clinical Surgical Sciences, University of the West Indies, St Augustine 000000, Trinidad and Tobago
| | - Parul Shukla
- Department of Surgery, Weill Cornell Medical College, New York, NY 10065, United States
| | - Rahul R Deshpande
- Department of Surgery, Manchester Royal Infirmary, Manchester M13 9WL, United Kingdom
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Karunakaran M, Jonnada PK, Chandrashekhar SH, Vinayachandran G, Kaambwa B, Barreto SG. Enhancing the cost-effectiveness of surgical care in pancreatic cancer: a systematic review and cost meta-analysis with trial sequential analysis. HPB (Oxford) 2022; 24:309-321. [PMID: 34848126 DOI: 10.1016/j.hpb.2021.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 10/21/2021] [Accepted: 11/07/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Clinical pathways (CP) based on Enhanced recovery after surgery (ERAS®) are increasingly utilised in patients undergoing pancreatoduodenectomy (PD). This systematic review aimed to compare the impact of CPs versus conventional care (CC) on peri-PD costs. METHODS A systematic review of major reference databases was undertaken. Quality assessment was performed using the CHEERS checklist. Incremental cost-effectiveness ratios were calculated as part of the cost-effectiveness analysis. A meta-analysis was performed using random-effects models and Trial sequential analysis (TSA) was used to assess the precision and conclusiveness of the results. RESULTS 14 studies meeting inclusion criteria were included for full qualitative synthesis. All studies reported a reduction in overall costs, length of stay and overall complication rates for CPs when compared to CC. Meta-analysis performed on nine studies demonstrated significantly reduced costs in the CP group, with considerable heterogeneity (Pooled mean difference of $ 4.28 × 103, p < 0.01, I2 = 95%). Cost-effectiveness analysis in relation to complications demonstrated dominance of CPs over CC in being cheaper as well as more effective. TSA supported the cost benefit of enhanced-recovery CPs, displaying minimal type 1 error. CONCLUSION Peri-PD CPs result in significant cost-reduction in comparison to CC.
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Affiliation(s)
- Monish Karunakaran
- Department of Surgical Gastroenterology, SK Hospital, Thiruvananthapuram, India
| | - Pavan K Jonnada
- Department of Surgical Oncology, Basavatarakam Indo-American Cancer Hospital & Research Institute, Hyderabad, India
| | - Sagar H Chandrashekhar
- Department of Gastrointestinal Surgery, Gastrointestinal Oncology, and Bariatric Surgery, Medanta- The Medicity, Gurgaon, India
| | | | - Billingsley Kaambwa
- College of Medicine and Public Health, Flinders University, South Australia, Australia
| | - Savio G Barreto
- College of Medicine and Public Health, Flinders University, South Australia, Australia; Division of Surgery and Perioperative Medicine, Flinders Medical Center, Bedford Park, Adelaide, South Australia, Australia.
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Halle-Smith JM, Hodson J, Coldham C, Dasari B, Chatzizacharias N, Marudanayagam R, Sutcliffe R, Isaac J, Mirza DF, Roberts KJ. Three decades of change in pancreatoduodenectomy and future prediction of pathological and operative complexity. Br J Surg 2022; 109:247-250. [PMID: 35026008 DOI: 10.1093/bjs/znab433] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 11/02/2021] [Accepted: 11/18/2021] [Indexed: 11/05/2023]
Abstract
Despite increasing complexity of surgery and patient age, the duration of hospital stay and mortality rate after pancreatoduodenectomy are decreasing. Understanding changes over time permits an estimation of a future surgical cohort in which complexity will increase. It is important that surgeons continue to push boundaries.
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Affiliation(s)
- James M Halle-Smith
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - James Hodson
- Medical Statistics, Institute of Translational Medicine, Birmingham, UK
| | - Chris Coldham
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Bobby Dasari
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
| | | | - Ravi Marudanayagam
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Robert Sutcliffe
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - John Isaac
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
| | - Darius F Mirza
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
- Centre for Liver and Gastrointestinal Research, University of Birmingham, Birmingham, UK
| | - Keith J Roberts
- Hepatobiliary and Pancreatic Surgery Unit, Queen Elizabeth Hospital, Birmingham, UK
- Centre for Liver and Gastrointestinal Research, University of Birmingham, Birmingham, UK
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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12
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Reddy AV, Sehgal S, Hill CS, Zheng L, He J, Herman JM, Meyer J, Narang AK. Upfront Chemotherapy Followed by Stereotactic Body Radiation Therapy with or without Surgery in Older Patients with Localized Pancreatic Cancer: A Single Institution Experience and Review of the Literature. Curr Oncol 2022; 29:308-320. [PMID: 35049702 PMCID: PMC8774377 DOI: 10.3390/curroncol29010028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 12/30/2021] [Accepted: 01/10/2022] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To report on clinical outcomes and toxicity in older (age ≥ 70 years) patients with localized pancreatic cancer treated with upfront chemotherapy followed by stereotactic body radiation therapy (SBRT) with or without surgery. METHODS Endpoints included overall survival (OS), local progression-free survival (LPFS), distant metastasis-free survival (DMFS), progression-free survival (PFS), and toxicity. RESULTS A total of 57 older patients were included in the study. Median OS was 19.6 months, with six-month, one-year, and two-year OS rates of 83.4, 66.5, and 42.4%. On MVA, resection status (HR: 0.30, 95% CI 0.12-0.91, p = 0.031) was associated with OS. Patients with surgically resected tumors had improved median OS (29.1 vs. 7.0 months, p < 0.001). On MVA, resection status (HR: 0.40, 95% CI 0.17-0.93, p = 0.034) was also associated with PFS. Patients with surgically resected tumors had improved median PFS (12.9 vs. 1.6 months, p < 0.001). There were 3/57 cases (5.3%) of late grade 3 radiation toxicity and 2/38 cases (5.3%) of Clavien-Dindo grade 3b toxicity in those who underwent resection. CONCLUSION Multimodality therapy involving SBRT is safe and feasible in older patients with localized pancreatic cancer. Surgical resection was associated with improved clinical outcomes. As such, older patients who complete chemotherapy should not be excluded from aggressive local therapy when possible.
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Affiliation(s)
- Abhinav V. Reddy
- Department of Radiation Oncology & Molecular Radiation Sciences, Sidney Kimmel Cancer Center, Johns Hopkins University School of Medicine, 401 N Broadway, Baltimore, MD 21231, USA; (S.S.); (C.S.H.); (J.M.); (A.K.N.)
| | - Shuchi Sehgal
- Department of Radiation Oncology & Molecular Radiation Sciences, Sidney Kimmel Cancer Center, Johns Hopkins University School of Medicine, 401 N Broadway, Baltimore, MD 21231, USA; (S.S.); (C.S.H.); (J.M.); (A.K.N.)
| | - Colin S. Hill
- Department of Radiation Oncology & Molecular Radiation Sciences, Sidney Kimmel Cancer Center, Johns Hopkins University School of Medicine, 401 N Broadway, Baltimore, MD 21231, USA; (S.S.); (C.S.H.); (J.M.); (A.K.N.)
| | - Lei Zheng
- Department of Oncology, Sidney Kimmel Cancer Center, Johns Hopkins University School of Medicine, 401 N Broadway, Baltimore, MD 21231, USA;
| | - Jin He
- Department of Surgery, Sidney Kimmel Cancer Center, Johns Hopkins University School of Medicine, 401 N Broadway, Baltimore, MD 21231, USA;
| | - Joseph M. Herman
- Department of Radiation Oncology, Northwell Health, 450 Lakeville Road, New Hyde Park, NY 11042, USA;
| | - Jeffrey Meyer
- Department of Radiation Oncology & Molecular Radiation Sciences, Sidney Kimmel Cancer Center, Johns Hopkins University School of Medicine, 401 N Broadway, Baltimore, MD 21231, USA; (S.S.); (C.S.H.); (J.M.); (A.K.N.)
| | - Amol K. Narang
- Department of Radiation Oncology & Molecular Radiation Sciences, Sidney Kimmel Cancer Center, Johns Hopkins University School of Medicine, 401 N Broadway, Baltimore, MD 21231, USA; (S.S.); (C.S.H.); (J.M.); (A.K.N.)
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13
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Gemenetzis G, McKay S, Pathak S, Moir J, Laing R, Jamieson NB, Young AL, Chatzizacharias NA, Giovinazzo F, Roberts KJ. Surgical Management of Non-Metastatic Pancreatic Cancer in the United Kingdom: Results of a Nationwide Survey on Current Practice. Front Oncol 2021; 11:791946. [PMID: 35004314 PMCID: PMC8733562 DOI: 10.3389/fonc.2021.791946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 12/01/2021] [Indexed: 11/13/2022] Open
Abstract
BackgroundIt is presently unclear what clinical pathways are followed for patients with non-metastatic PDAC in specialised centres for pancreatic surgery across the United Kingdom (UK).MethodsBetween August 2019 and August 2020 an electronic survey was conducted aiming at a national cohort of pancreatic surgeons in the UK. Participants replied to a list of standardised questions and clinical vignettes, and data were collected and analysed focusing on management preferences, resectability criteria, and contraindications to surgery.ResultsWithin the study period, 65 pancreatic surgeons from 27 specialist centres in the UK (96%) completed the survey. Multidisciplinary team meetings are utilised universally for the management of patients with PDAC, however, different staging systems for resectability classification are being applied. In borderline resectable PDAC, most surgeons were keen to proceed with surgical exploration post NAT, but differences were noted in preferred chemotherapy regimens. Surgeons from standard volume institutions performed fewer vein resections annually and were more likely to deem patients with locally advanced PDAC as unresectable. Intra-institutional variability in patient management was also present and ranging between 20-80%.ConclusionsSignificant variability in the surgical management of non-metastatic PDAC was identified both on inter- and intra-institutional level.
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Affiliation(s)
- Georgios Gemenetzis
- Department of Hepatobiliary (HPB) and Transplant Surgery, Royal Infirmary Edinburgh, Edinburgh, United Kingdom
- *Correspondence: Keith J. Roberts, ; Georgios Gemenetzis,
| | - Siobhan McKay
- Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, United Kingdom
| | - Samir Pathak
- Department of Surgery, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | - John Moir
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, The Freeman Hospital, Newcastle, United Kingdom
| | - Richard Laing
- Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, United Kingdom
| | - Nigel B. Jamieson
- West of Scotland Pancreatic Unit, Glasgow Royal Infirmary, Glasgow, United Kingdom
| | - Alastair L. Young
- Department of Pancreatic Surgery, St James’s University Hospital, Leeds, United Kingdom
| | | | - Francesco Giovinazzo
- Department of General Surgery and Liver Transplantation, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Keith J. Roberts
- Liver Unit, Queen Elizabeth University Hospital Birmingham, Birmingham, United Kingdom
- *Correspondence: Keith J. Roberts, ; Georgios Gemenetzis,
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14
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Mitsakos AT, Vohra NA, Fitzgerald TL, Buccini P, Parikh AA, Snyder RA, Zervos EE. Improvement in Surgical Quality Following Pancreaticoduodenectomy With Increasing Case Volume in a Rural Hospital. Am Surg 2021; 88:746-751. [PMID: 34792413 DOI: 10.1177/00031348211050808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The literature is replete with studies that define the nexus of quantity and quality in complex surgical operations. These observations have heralded a call for centralization of care to high-volume centers. The purpose of this study was to chronicle improvements in quality associated with pancreaticoduodenectomy (PD) as a rural hospital matures from a low- to very high-volume center. METHODS A retrospective review of a prospective pancreatic surgery database was undertaken from July 2007 to June 2020. Annual periods were characterized as low (≤12/year), high (13-29/year), and very high volume (≥30/year). Data for the following quality benchmarks were aggregated and compared: length of stay (LOS), 30-day readmissions, 30-day mortality, and 1- and 3-year survival. A subgroup analysis was undertaken in those patients undergoing PD for adenocarcinoma detailing margin status and number of lymph nodes harvested. Outcomes were compared using the Fisher's exact and Student's t-test. RESULTS 375 PD were completed over the 13-year period; 62.1% were undertaken for ductal adenocarcinoma. There was a significant decrease in LOS and 30-day readmissions as the institution matured toward very high volume. There were no significant differences in 30-day mortality, 1- and 3-year survival, or margin negativity rates associated with volume. Extent of lymph node harvest significantly improved as institutional experience increased. DISCUSSION Our pancreatic surgery program matured rapidly from low to very high volume with institutional commitment and dedicated resources. As the institution matured, operational efficiencies and surgical quality improved. Not unexpectedly, biology trumped volume as reflected in 1- and 3-year survival rates.
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Affiliation(s)
- Anastasios T Mitsakos
- Department of Surgery, Division of Surgical Oncology, 12278Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Nasreen A Vohra
- Department of Surgery, Division of Surgical Oncology, 12278Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Timothy L Fitzgerald
- Department of Surgery, Division of Surgical Oncology, 92602Maine Medical Center, Portland, ME, USA
| | - Peter Buccini
- Department of Surgery, Division of Surgical Oncology, 12278Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Alexander A Parikh
- Department of Surgery, Division of Surgical Oncology, 12278Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Rebecca A Snyder
- Department of Surgery, Division of Surgical Oncology, 12278Brody School of Medicine at East Carolina University, Greenville, NC, USA
| | - Emmanuel E Zervos
- Department of Surgery, Division of Surgical Oncology, 12278Brody School of Medicine at East Carolina University, Greenville, NC, USA
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15
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Blair AB, Krell RW, Ejaz A, Groot VP, Gemenetzis G, Padussis JC, Falconi M, Wolfgang CL, Weiss MJ, Are C, He J, Reames BN. Proclivity to Explore Locally Advanced Pancreas Cancer Is Not Associated with Surgeon Volume. J Gastrointest Surg 2021; 25:2562-2571. [PMID: 34027578 DOI: 10.1007/s11605-021-05034-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 04/28/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND PURPOSE There is limited high-level evidence to guide locally advanced pancreas cancer (LAPC) management. Recent work shows that surgeons' preferences in LAPC management vary broadly. We sought to examine whether surgeon volume was associated with attitudes regarding LAPC management. METHODS An electronic survey was distributed by email to an international cohort of pancreas surgeons to evaluate practice patterns regarding LAPC management. Clinical vignette-based questions evaluated surgeons' attitudes regarding patient eligibility and the proclivity to offer exploration. Surgeons were classified into "low-" or "high-volume" categories according to thresholds of self-reported annual pancreatectomy volume. Surgeon's attitudes regarding LAPC management and inclination to consider exploration were compared across annual volume categories. RESULTS A total of 153 eligible responses were received from 4 continents, for an estimated response rate of 10.6%. Median duration of practice was 12 years (IQR 6-20). Most respondents reported >25 cases/year (89, 58.2%), of which 34 (22.2%) reported >50. Compared to surgeons with <25 cases/year, surgeons with >25 cases/year practiced longer (median 15 vs. 7.5 years, P<0.001) and were more likely to "always" recommend neoadjuvant chemotherapy (83.2% vs. 56.3%, P=0.001). Surgeons performing >50 cases/year were more likely to offer arterial resection (70.6% vs. 43.7%, P=0.006). The willingness to offer (or defer) exploration did not differ across any categories of surgeons' annual case volume. CONCLUSIONS In an international survey of pancreas surgeons, the proclivity to consider exploration for LAPC was not associated with multiple categories of surgeon volume. Better evidence is needed to define the optimal management approach to LAPC.
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Affiliation(s)
- Alex B Blair
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Robert W Krell
- Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Aslam Ejaz
- Department of Surgery, Ohio State University, Columbus, OH, USA
| | - Vincent P Groot
- Department of Surgery, UMC Utrecht Cancer Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Georgios Gemenetzis
- Department of Surgery, University of Glasgow School of Medicine, Glasgow, UK
| | - James C Padussis
- Department of Surgery, Division of Surgical Oncology, University of Nebraska Medical Center, 986880 Nebraska Medical Center, Omaha, NE, 68198, USA
| | - Massimo Falconi
- Department of Surgery, Università Vita-Salute, San Raffaele Hospital IRCCS, Milano, Italy
| | | | | | - Chandrakanth Are
- Department of Surgery, Division of Surgical Oncology, University of Nebraska Medical Center, 986880 Nebraska Medical Center, Omaha, NE, 68198, USA
| | - Jin He
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Bradley N Reames
- Department of Surgery, Division of Surgical Oncology, University of Nebraska Medical Center, 986880 Nebraska Medical Center, Omaha, NE, 68198, USA.
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16
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Klompmaker S, van der Vliet WJ, Thoolen SJ, Ore AS, Verkoulen K, Solis-Velasco M, Canacari EG, Kruskal JB, Khwaja KO, Tseng JF, Callery MP, Kent TS, Moser AJ. Procedure-specific Training for Robot-assisted Distal Pancreatectomy. Ann Surg 2021; 274:e18-e27. [PMID: 30946088 DOI: 10.1097/sla.0000000000003291] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To train practicing surgeons in robot-assisted distal pancreatectomy (RADP) and assess the impact on 5 domains of healthcare quality. BACKGROUND RADP may reduce the treatment burden compared with open distal pancreatectomy (ODP), but studies on institutional training and implementation programs are scarce. METHODS A retrospective, single-center, cohort study evaluating surgical performance during a procedure-specific training program for RADP (January 2006 to September 2017). Baseline and unadjusted outcomes were compared "before training" (ODP only; June 2012). Exclusion criteria were neoadjuvant therapy, vascular- and unrelated organ resection. Run charts evaluated index length of stay (LOS) and 90-day comprehensive complication index. Cumulative sum charts of operating time (OT) assessed institutional learning. Adjusted outcomes after RADP versus ODP were compared using a secondary propensity-score-matched (1:1) analysis to determine clinical efficacy. RESULTS After screening, 237 patients were included in the before-training (133 ODP) and after-training (24 ODP, 80 RADP) groups. After initiation of training, mean perioperative blood loss decreased (-255 mL, P<0.001), OT increased (+65 min, P < 0.001), and median LOS decreased (-1 day, P < 0.001). All other outcomes remained similar (P>0.05). Over time, there were nonrandom (P < 0.05) downward shifts in LOS, while comprehensive complication index was unaffected. We observed 3 learning curve phases in OT: accumulation (<31 cases), optimization (case 31-65), and a steady-state (>65 cases). Propensity-score-matching confirmed reductions in index and 90-day LOS and blood loss with similar morbidity between RADP and ODP. CONCLUSION Supervised procedure-specific training enabled successful implementation of RADP by practicing surgeons with immediate improvements in length of stay, without adverse effects on safety.
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Affiliation(s)
- Sjors Klompmaker
- Beth Israel Deaconess Medical Center, Harvard Medical School, Pancreas and Liver Institute, Boston, MA
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Walderik J van der Vliet
- Beth Israel Deaconess Medical Center, Harvard Medical School, Pancreas and Liver Institute, Boston, MA
- Department of Surgery, Maastricht University Medical Center, Maastricht University, Maastricht, The Netherlands
| | - Stijn J Thoolen
- Beth Israel Deaconess Medical Center, Harvard Medical School, Pancreas and Liver Institute, Boston, MA
| | - Ana Sofia Ore
- Beth Israel Deaconess Medical Center, Harvard Medical School, Pancreas and Liver Institute, Boston, MA
| | - Koen Verkoulen
- Beth Israel Deaconess Medical Center, Harvard Medical School, Pancreas and Liver Institute, Boston, MA
- Department of Surgery, Maastricht University Medical Center, Maastricht University, Maastricht, The Netherlands
| | - Monica Solis-Velasco
- Beth Israel Deaconess Medical Center, Harvard Medical School, Pancreas and Liver Institute, Boston, MA
| | - Elena G Canacari
- Department of Nursing, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jonathan B Kruskal
- Medical Executive Committee, Beth Israel Deaconess Medical Center, Boston, MA
| | - Khalid O Khwaja
- The Transplant Center, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jennifer F Tseng
- Department of Surgery, Boston Medical Center, Boston University, Boston, MA
| | - Mark P Callery
- Beth Israel Deaconess Medical Center, Harvard Medical School, Pancreas and Liver Institute, Boston, MA
| | - Tara S Kent
- Beth Israel Deaconess Medical Center, Harvard Medical School, Pancreas and Liver Institute, Boston, MA
| | - A James Moser
- Beth Israel Deaconess Medical Center, Harvard Medical School, Pancreas and Liver Institute, Boston, MA
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17
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Reames BN, Blair AB, Krell RW, Groot VP, Gemenetzis G, Padussis JC, Thayer SP, Falconi M, Wolfgang CL, Weiss MJ, Are C, He J. Management of Locally Advanced Pancreatic Cancer: Results of an International Survey of Current Practice. Ann Surg 2021; 273:1173-1181. [PMID: 31449138 DOI: 10.1097/sla.0000000000003568] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The aim of this study was to investigate surgeon preferences for the management of patients with locally advanced pancreatic cancer (LAPC). BACKGROUND Select patients with LAPC may become candidates for curative resection following neoadjuvant therapy, and recent reports of survival are encouraging. Yet the optimal management approach remains unclear. METHODS An extensive electronic survey was systematically distributed by email to an international cohort of pancreas surgeons. Data collected included practice characteristics, management preferences, attitudes regarding contraindications to surgery, and 6 clinical vignettes of patients that ultimately received a margin negative resection (with detailed videos of post-neoadjuvant imaging) to assess propensity for surgical exploration if resection status is not known. RESULTS A total of 153 eligible responses were received from 4 continents. Median duration of practice is 12 years (interquartile range 6-20) and 77% work in a university setting. Most surgeons (86%) are considered high volume (>10 resections/yr), 33% offer a minimally-invasive approach, and 50% offer arterial resections in select patients. Most (72%) always recommend neoadjuvant chemotherapy, and 65% prefer FOLFIRINOX. Preferences for the duration of chemotherapy varied widely: 39% prefer ≥2 months, 43% prefer ≥4 months, and 11% prefer ≥6 months. Forty-one percent frequently recommend neoadjuvant radiotherapy, and 53% prefer 5 to 6 weeks of chemoradiation. The proportion of surgeons favoring exploration following neoadjuvant varied extensively across 5 vignettes of LAPC, from 14% to 53%. In a vignette of oligometastatic liver metastases, 31% would offer exploration if a favorable therapy response is observed. CONCLUSIONS In an international cohort of pancreas surgeons, there is substantial variation in management preferences, perceived contraindications to surgery, and the propensity to consider exploration in LAPC. These results emphasize the importance of a robust and nuanced multidisciplinary discussion for each patient, and suggest an evolving concept of "resectability."
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Affiliation(s)
- Bradley N Reames
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Alex B Blair
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
| | - Robert W Krell
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Vincent P Groot
- Department of Surgery, UMC Utrecht Cancer Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Georgios Gemenetzis
- Department of Surgery, University of Glasgow School of Medicine, Glasgow, UK
| | - James C Padussis
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Sarah P Thayer
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Massimo Falconi
- Department of Surgery, Università Vita-Salute, San Raffaele Hospital IRCCS, Milano, Italy
| | | | | | - Chandrakanth Are
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Jin He
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD
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18
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Moya-Herraiz AA, Dorcaratto D, Martin-Perez E, Escrig-Sos J, Poves-Prim I, Fabregat-Prous J, Larrea Y Olea J, Sanchez-Bueno F, Botello-Martinez F, Sabater L. Non-arbitrary minimum threshold of yearly performed pancreatoduodenectomies: National multicentric study. Surgery 2021; 170:910-916. [PMID: 33875253 DOI: 10.1016/j.surg.2021.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 02/11/2021] [Accepted: 03/06/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Annual hospital volume of pancreatoduodenectomies could influence postoperative outcomes. The aim of this study is to establish with a non-arbitrary method the minimum threshold of yearly performed pancreatoduodenectomies in order to improve several postoperative quality outcomes. METHOD Prospective follow-up of patients submitted to pancreatoduodenectomy in participating hospitals during 1 year. The influence of hospital volume on quality outcomes was analyzed by univariable and multivariable models. The minimum threshold of yearly performed pancreatoduodenectomies to improve outcomes was established by Akaike's information criteria. RESULTS Data from 877 patients operated in 74 hospitals were analyzed. Of 12 quality outcomes, 9 were influenced by hospital pancreatoduodenectomy volume on multivariable analysis. To decrease the risk of complications and the risk of retrieving an insufficient number of lymph nodes at least 31 pancreatoduodenectomies per year should be performed. To decrease the risk of prolonged length of stay, postoperative death, and affected surgical margins, at least 37, 6, and 14 pancreatoduodenectomies per year should be performed, respectively. CONCLUSION Several postoperative quality outcomes are influenced by the number of yearly performed pancreatoduodenectomies and could be improved by establishing a minimum threshold of procedures. Number of procedures needed to improve quality outcomes has been established by a non-arbitrary method.
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Affiliation(s)
- Angel Antonio Moya-Herraiz
- Department of Surgery, HPB unit, Hospital General Universitario de Castelló, Castelló de la Plana, Castellón, Spain
| | - Dimitri Dorcaratto
- Department of Surgery, Liver, Biliary and Pancreatic Unit, Hospital Clínico, University of Valencia, Biomedical Research Institute (INCLIVA), Valencia, Spain.
| | | | - Javier Escrig-Sos
- Department of Surgery, Hospital General Universitario de Castelló, Castelló de la Plana, Castellón, Spain
| | | | - Joan Fabregat-Prous
- Department of Surgery, Hospital Universitari Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Javier Larrea Y Olea
- Department of Surgery, Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Las Palmas, Spain
| | | | | | - Luis Sabater
- Department of Surgery, Liver, Biliary and Pancreatic Unit, Hospital Clínico, University of Valencia, Biomedical Research Institute (INCLIVA), Valencia, Spain
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19
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Permuth JB, Dezsi KB, Vyas S, Ali KN, Basinski TL, Utuama OA, Denbo JW, Klapman J, Dam A, Carballido E, Kim DW, Pimiento JM, Powers BD, Otto AK, Choi JW, Chen DT, Teer JK, Beato F, Ward A, Cortizas EM, Whisner SY, Williams IE, Riner AN, Tardif K, Velanovich V, Karachristos A, Douglas WG, Legaspi A, Allan BJ, Meredith K, Molina-Vega MA, Bao P, St. Julien J, Huguet KL, Green L, Odedina FT, Kumar NB, Simmons VN, George TJ, Vadaparampil ST, Hodul PJ, Arnoletti JP, Awad ZT, Bose D, Jiang K, Centeno BA, Gwede CK, Malafa M, Judge SM, Judge AR, Jeong D, Bloomston M, Merchant NB, Fleming JB, Trevino JG. The Florida Pancreas Collaborative Next-Generation Biobank: Infrastructure to Reduce Disparities and Improve Survival for a Diverse Cohort of Patients with Pancreatic Cancer. Cancers (Basel) 2021; 13:809. [PMID: 33671939 PMCID: PMC7919015 DOI: 10.3390/cancers13040809] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 02/02/2021] [Accepted: 02/05/2021] [Indexed: 12/15/2022] Open
Abstract
Background: Well-annotated, high-quality biorepositories provide a valuable platform to support translational research. However, most biorepositories have poor representation of minority groups, limiting the ability to address health disparities. Methods: We describe the establishment of the Florida Pancreas Collaborative (FPC), the first state-wide prospective cohort study and biorepository designed to address the higher burden of pancreatic cancer (PaCa) in African Americans (AA) compared to Non-Hispanic Whites (NHW) and Hispanic/Latinx (H/L). We provide an overview of stakeholders; study eligibility and design; recruitment strategies; standard operating procedures to collect, process, store, and transfer biospecimens, medical images, and data; our cloud-based data management platform; and progress regarding recruitment and biobanking. Results: The FPC consists of multidisciplinary teams from fifteen Florida medical institutions. From March 2019 through August 2020, 350 patients were assessed for eligibility, 323 met inclusion/exclusion criteria, and 305 (94%) enrolled, including 228 NHW, 30 AA, and 47 H/L, with 94%, 100%, and 94% participation rates, respectively. A high percentage of participants have donated blood (87%), pancreatic tumor tissue (41%), computed tomography scans (76%), and questionnaires (62%). Conclusions: This biorepository addresses a critical gap in PaCa research and has potential to advance translational studies intended to minimize disparities and reduce PaCa-related morbidity and mortality.
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Affiliation(s)
- Jennifer B. Permuth
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (K.B.D.); (S.V.); (K.N.A.); (T.L.B.); (O.A.U.); (N.B.K.)
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (J.W.D.); (J.K.); (A.D.); (E.C.); (D.W.K.); (J.M.P.); (B.D.P.); (F.B.); (P.J.H.); (M.M.); (J.B.F.)
| | - Kaleena B. Dezsi
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (K.B.D.); (S.V.); (K.N.A.); (T.L.B.); (O.A.U.); (N.B.K.)
| | - Shraddha Vyas
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (K.B.D.); (S.V.); (K.N.A.); (T.L.B.); (O.A.U.); (N.B.K.)
| | - Karla N. Ali
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (K.B.D.); (S.V.); (K.N.A.); (T.L.B.); (O.A.U.); (N.B.K.)
| | - Toni L. Basinski
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (K.B.D.); (S.V.); (K.N.A.); (T.L.B.); (O.A.U.); (N.B.K.)
| | - Ovie A. Utuama
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (K.B.D.); (S.V.); (K.N.A.); (T.L.B.); (O.A.U.); (N.B.K.)
| | - Jason W. Denbo
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (J.W.D.); (J.K.); (A.D.); (E.C.); (D.W.K.); (J.M.P.); (B.D.P.); (F.B.); (P.J.H.); (M.M.); (J.B.F.)
| | - Jason Klapman
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (J.W.D.); (J.K.); (A.D.); (E.C.); (D.W.K.); (J.M.P.); (B.D.P.); (F.B.); (P.J.H.); (M.M.); (J.B.F.)
| | - Aamir Dam
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (J.W.D.); (J.K.); (A.D.); (E.C.); (D.W.K.); (J.M.P.); (B.D.P.); (F.B.); (P.J.H.); (M.M.); (J.B.F.)
| | - Estrella Carballido
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (J.W.D.); (J.K.); (A.D.); (E.C.); (D.W.K.); (J.M.P.); (B.D.P.); (F.B.); (P.J.H.); (M.M.); (J.B.F.)
| | - Dae Won Kim
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (J.W.D.); (J.K.); (A.D.); (E.C.); (D.W.K.); (J.M.P.); (B.D.P.); (F.B.); (P.J.H.); (M.M.); (J.B.F.)
| | - Jose M. Pimiento
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (J.W.D.); (J.K.); (A.D.); (E.C.); (D.W.K.); (J.M.P.); (B.D.P.); (F.B.); (P.J.H.); (M.M.); (J.B.F.)
| | - Benjamin D. Powers
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (J.W.D.); (J.K.); (A.D.); (E.C.); (D.W.K.); (J.M.P.); (B.D.P.); (F.B.); (P.J.H.); (M.M.); (J.B.F.)
| | - Amy K. Otto
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL 33612, USA;
| | - Jung W. Choi
- Department of Diagnostic Imaging and Interventional Radiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (J.W.C.); (D.J.)
| | - Dung-Tsa Chen
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (D.-T.C.); (J.K.T.)
| | - Jamie K. Teer
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (D.-T.C.); (J.K.T.)
| | - Francisca Beato
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (J.W.D.); (J.K.); (A.D.); (E.C.); (D.W.K.); (J.M.P.); (B.D.P.); (F.B.); (P.J.H.); (M.M.); (J.B.F.)
| | - Alina Ward
- Lee Health Regional Cancer Center, Fort Myers, FL 33905, USA; (A.W.); (B.J.A.); (M.B.)
| | - Elena M. Cortizas
- Sylvester Comprehensive Cancer Center, Miller School of Medicine, University of Miami, Miami, FL 33136, USA;
| | | | - Iverson E. Williams
- College of Medicine, University of Florida, Gainesville, FL 32610, USA; (I.E.W.); (A.N.R.); (J.G.T.)
| | - Andrea N. Riner
- College of Medicine, University of Florida, Gainesville, FL 32610, USA; (I.E.W.); (A.N.R.); (J.G.T.)
| | - Kenneth Tardif
- Department of Surgery, St. Anthony’s Hospital, St. Petersburg, FL 33705, USA; (K.T.); (J.S.J.); (K.L.H.)
| | - Vic Velanovich
- Tampa General Hospital, University of South Florida, Tampa, FL 33606, USA; (V.V.); (A.K.)
| | - Andreas Karachristos
- Tampa General Hospital, University of South Florida, Tampa, FL 33606, USA; (V.V.); (A.K.)
| | - Wade G. Douglas
- Division of Surgery, Tallahassee Memorial Healthcare, Department of Clinical Sciences, College of Medicine, Florida State University, Tallahassee, FL 32308, USA;
| | - Adrian Legaspi
- Center for Advanced Surgical Oncology at Palmetto General Hospital, Tenet Healthcare Palmetto General, Hialeah, FL 33016, USA;
| | - Bassan J. Allan
- Lee Health Regional Cancer Center, Fort Myers, FL 33905, USA; (A.W.); (B.J.A.); (M.B.)
| | - Kenneth Meredith
- Department of Gastrointestinal Oncology, Brian Jellison Cancer Institute, Sarasota Memorial Hospital, Sarasota, FL 34239, USA;
| | | | - Philip Bao
- Department of Surgical Oncology, Mount Sinai Medical Center, Miami Beach, FL 33140, USA;
| | - Jamii St. Julien
- Department of Surgery, St. Anthony’s Hospital, St. Petersburg, FL 33705, USA; (K.T.); (J.S.J.); (K.L.H.)
| | - Kevin L. Huguet
- Department of Surgery, St. Anthony’s Hospital, St. Petersburg, FL 33705, USA; (K.T.); (J.S.J.); (K.L.H.)
| | - Lee Green
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (L.G.); (V.N.S.); (S.T.V.); (C.K.G.)
| | - Folakemi T. Odedina
- Department of Pharmacotherapy and Translational Research, University of Florida, Gainesville, FL 32610, USA;
| | - Nagi B. Kumar
- Department of Cancer Epidemiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (K.B.D.); (S.V.); (K.N.A.); (T.L.B.); (O.A.U.); (N.B.K.)
| | - Vani N. Simmons
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (L.G.); (V.N.S.); (S.T.V.); (C.K.G.)
| | - Thomas J. George
- Division of Oncology, Department of Medicine, University of Florida, Gainesville, FL 32610, USA;
| | - Susan T. Vadaparampil
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (L.G.); (V.N.S.); (S.T.V.); (C.K.G.)
- Office of Community Outreach, Engagement, and Equity, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA
| | - Pamela J. Hodul
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (J.W.D.); (J.K.); (A.D.); (E.C.); (D.W.K.); (J.M.P.); (B.D.P.); (F.B.); (P.J.H.); (M.M.); (J.B.F.)
| | - J. Pablo Arnoletti
- Center for Surgical Oncology, Advent Health Orlando, Orlando, FL 32804, USA;
| | - Ziad T. Awad
- Surgery, University of Florida-Jacksonville, Jacksonville, FL 32209, USA;
| | - Debashish Bose
- Surgical Oncology, University of Florida-Orlando, Orlando, FL 32806, USA;
| | - Kun Jiang
- Department of Pathology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (K.J.); (B.A.C.)
| | - Barbara A. Centeno
- Department of Pathology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (K.J.); (B.A.C.)
| | - Clement K. Gwede
- Department of Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (L.G.); (V.N.S.); (S.T.V.); (C.K.G.)
| | - Mokenge Malafa
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (J.W.D.); (J.K.); (A.D.); (E.C.); (D.W.K.); (J.M.P.); (B.D.P.); (F.B.); (P.J.H.); (M.M.); (J.B.F.)
| | - Sarah M. Judge
- Department of Physical Therapy, University of Florida, Gainesville, FL 32610, USA; (S.M.J.); (A.R.J.)
| | - Andrew R. Judge
- Department of Physical Therapy, University of Florida, Gainesville, FL 32610, USA; (S.M.J.); (A.R.J.)
| | - Daniel Jeong
- Department of Diagnostic Imaging and Interventional Radiology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (J.W.C.); (D.J.)
| | - Mark Bloomston
- Lee Health Regional Cancer Center, Fort Myers, FL 33905, USA; (A.W.); (B.J.A.); (M.B.)
| | - Nipun B. Merchant
- Department of Surgical Oncology, Miller School of Medicine, University of Miami, Miami, FL 33136, USA;
| | - Jason B. Fleming
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA; (J.W.D.); (J.K.); (A.D.); (E.C.); (D.W.K.); (J.M.P.); (B.D.P.); (F.B.); (P.J.H.); (M.M.); (J.B.F.)
| | - Jose G. Trevino
- College of Medicine, University of Florida, Gainesville, FL 32610, USA; (I.E.W.); (A.N.R.); (J.G.T.)
- Division of Surgical Oncology, Department of Surgery, School of Medicine, Virginia Commonwealth University, Richmond, VA 23219, USA
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20
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Yu AHK, Chan ACY. Pre‐operative diabetes mellitus does not worsen survival and post‐operative outcomes in
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hinese patients undergoing resection for pancreatic adenocarcinoma. SURGICAL PRACTICE 2020. [DOI: 10.1111/1744-1633.12453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Adrian H. K. Yu
- Division of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Department of Surgery University of Hong Kong Hong Kong China
| | - Albert C. Y. Chan
- Division of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Department of Surgery University of Hong Kong Hong Kong China
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21
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Should all pancreatic surgery be centralized regardless of patients' comorbidity? HPB (Oxford) 2020; 22:1057-1066. [PMID: 31784212 DOI: 10.1016/j.hpb.2019.10.2443] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 10/27/2019] [Accepted: 10/29/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND It remains to be established whether centralization to high volume centers is essential for all patients undergoing pancreatic surgery. The aims of this study were to identify the optimal cut-off volume to optimize patient outcomes and to determine if patient comorbidity affected the volume-outcome relationship. METHODS Patients undergoing pancreatectomy from 2012 to 2015 were retrospectively identified (n = 12 333) in the French nationwide database. The 90-day Post-Operative Mortality (POM) was analyzed according to hospital volume of pancreatectomy (very low:<10, Low:10-19, High:20-49 and very high:≥50 resections/year) and Charlson Comorbidity Index (ChCI). RESULTS The overall POM was 6.9%. The cut-off of 20 pancreatic resections per year was identified as predictor of POM. Compared to high volume centers, POM was significantly higher in low and very low volume centers whatever the ChCl. Regarding surgical procedures, there was a significant decrease in POM with increasing hospital volume only after pancreaticoduodenectomy regardless of the ChCl. On multivariable analysis, low and very low volume centers were independently associated with increased mortality rates. CONCLUSION The optimal cut-off of annual caseload was 20 pancreatic resections. POM following pancreaticoduodenectomy is high in low and very low volume centers independently of ChCl, suggesting that this procedure should be centralized.
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22
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Comment on "Outcomes of a Multicenter Training Program in Laparoscopic Pancreatoduodenectomy (LAELAPS-2)". Ann Surg 2019; 270:e117-e118. [PMID: 31726638 DOI: 10.1097/sla.0000000000003333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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23
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Lu S, Khatri R, Tanner B, Shebrain S, Munene G. Short term outcomes and unintended benefits of establishing a HPB program at a university-affiliated community hospital. Am J Surg 2019; 218:946-951. [DOI: 10.1016/j.amjsurg.2019.03.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 03/09/2019] [Accepted: 03/13/2019] [Indexed: 12/12/2022]
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Pickens RC, Bloomer AK, Sulzer JK, Murphy K, Lyman WB, Iannitti DA, Martinie JB, Baker EH, Ocuin LM, Vrochides D, Matthews BD. Modifying Interhospital Hepatopancreatobiliary Transfers Based on Predictive Analytics: Moving from a Center of Excellence to a Health-Care System of Excellence. Am Surg 2019. [DOI: 10.1177/000313481908500949] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Regionalization of complex surgical care has increased interhospital transfers to quaternary centers within large health-care systems. Risk-based patient selection is imperative to improve resource allocation without compromising care. This study aimed to develop predictive models for identifying low-risk patients for transfer to a fully integrated satellite hepatopancreatobiliary (HPB) service in the northeast region of the health-care system. HPB transfers to the quaternary center over 15 months from hospitals in proximity to the satellite HPB center. A predictive tool was developed based on simple pretransfer variables and outcomes for 30-day major complications (Clavien grade ≥ 3), readmission, and mortality. Thresholds for “low risk” were set at different SDs below mean for each model. Predictive models were developed from 51 eligible northeast region patient transfers for major complications (Brier score 0.1948, receiver operator characteristic (ROC) 0.7123, P = 0.0009), readmission (Brier score 0.0615, ROC 0.7368, P = 0.0020), and mortality (Brier score 0.0943, ROC 0.7989, P = 0.0023). Thresholds set from 2 SD below the mean for all models identified 2 as “low risk.” Adjusting the threshold for the serious complication model to only 1 SD below the mean increased the “low-risk” cohort to five patients. These models demonstrate an easy-to-use tool to assist surgeons in identifying low-risk patients for diversion to a fully integrated satellite center. Improved interhospital transfers within a region could begin a transition from centers of excellence toward health-care systems of excellence.
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Affiliation(s)
- Ryan C. Pickens
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Ainsley K. Bloomer
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jesse K. Sulzer
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Keith Murphy
- Carolinas Center for Surgical Outcomes Science, Carolinas Medical Center, Charlotte, North Carolina; and
| | - William B. Lyman
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - David A. Iannitti
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - John B. Martinie
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Erin H. Baker
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Lee M. Ocuin
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Dionisios Vrochides
- Division of HPB Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Brent D. Matthews
- Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
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25
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Permuth JB, Clark Daly A, Jeong D, Choi JW, Cameron ME, Chen D, Teer JK, Barnett TE, Li J, Powers BD, Kumar NB, George TJ, Ali KN, Huynh T, Vyas S, Gwede CK, Simmons VN, Hodul PJ, Carballido EM, Judge AR, Fleming JB, Merchant N, Trevino JG. Racial and ethnic disparities in a state-wide registry of patients with pancreatic cancer and an exploratory investigation of cancer cachexia as a contributor to observed inequities. Cancer Med 2019; 8:3314-3324. [PMID: 31074202 PMCID: PMC6558500 DOI: 10.1002/cam4.2180] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 03/29/2019] [Accepted: 04/03/2019] [Indexed: 12/18/2022] Open
Abstract
Pancreatic cancer (PC) is characterized by racial/ethnic disparities and the debilitating muscle-wasting condition, cancer cachexia. Florida ranks second in the number of PC deaths and has a large and understudied minority population. We examined the primary hypothesis that PC incidence and mortality rates may be highest among Black Floridians and the secondary hypothesis that biological correlates of cancer cachexia may underlie disparities. PC incidence and mortality rates were estimated by race/ethnicity, gender, and county using publicly available state-wide cancer registry data that included approximately 2700 Black, 25 200 Non-Hispanic White (NHW), and 3300 Hispanic/Latino (H/L) Floridians diagnosed between 2004 and 2014. Blacks within Florida experienced a significantly (P < 0.05) higher incidence (12.5/100 000) and mortality (10.97/100 000) compared to NHW (incidence = 11.2/100 000; mortality = 10.3/100 000) and H/L (incidence = 9.6/100 000; mortality = 8.7/100 000), especially in rural counties. To investigate radiologic and blood-based correlates of cachexia, we leveraged data from a subset of patients evaluated at two geographically distinct Florida Cancer Centers. In Blacks compared to NHW matched on stage, markers of PC-induced cachexia were more frequent and included greater decreases in core musculature compared to corresponding healthy control patients (25.0% vs 10.1% lower), greater decreases in psoas musculature over time (10.5% vs 4.8% loss), lower baseline serum albumin levels (3.8 vs 4.0 gm/dL), and higher platelet counts (332.8 vs 268.7 k/UL). Together, these findings suggest for the first time that PC and cachexia may affect Blacks disproportionately. Given its nearly universal contribution to illness and PC-related deaths, the early diagnosis and treatment of cachexia may represent an avenue to improve health equity, quality of life, and survival.
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Affiliation(s)
- Jennifer B. Permuth
- Department of Cancer EpidemiologyMoffitt Cancer CenterTampaFlorida
- Department of Gastrointestinal OncologyMoffitt Cancer CenterTampaFlorida
| | - Ashley Clark Daly
- Division of Behavioral HealthIdaho Department of Health and WelfareBoiseIdaho
| | - Daniel Jeong
- Department of Diagnostic RadiologyMoffitt Cancer CenterTampaFlorida
| | - Jung W. Choi
- Department of Cancer Imaging & MetabolismMoffitt Cancer CenterTampaFlorida
| | - Miles E. Cameron
- Department of Surgery, Division of General SurgeryUniversity of Florida Health Sciences CenterGainesvilleFlorida
| | - Dung‐Tsa Chen
- Department of Biostatistics and BioinformaticsMoffitt Cancer CenterTampaFlorida
| | - Jamie K. Teer
- Department of Biostatistics and BioinformaticsMoffitt Cancer CenterTampaFlorida
| | - Tracey E. Barnett
- School of Public HealthUniversity of North Texas Health Science CenterFort WorthTexas
| | - Jiannong Li
- Department of Biostatistics and BioinformaticsMoffitt Cancer CenterTampaFlorida
| | - Benjamin D. Powers
- Department of Gastrointestinal OncologyMoffitt Cancer CenterTampaFlorida
| | | | - Thomas J. George
- Department of MedicineUniversity of Florida Health Sciences CenterGainesvilleFlorida
| | - Karla N. Ali
- Department of Cancer EpidemiologyMoffitt Cancer CenterTampaFlorida
| | - Tri Huynh
- Department of Cancer EpidemiologyMoffitt Cancer CenterTampaFlorida
| | - Shraddha Vyas
- Department of Cancer EpidemiologyMoffitt Cancer CenterTampaFlorida
| | - Clement K. Gwede
- Department of Health Outcomes and BehaviorMoffitt Cancer CenterTampaFlorida
| | - Vani N. Simmons
- Department of Health Outcomes and BehaviorMoffitt Cancer CenterTampaFlorida
| | - Pamela J. Hodul
- Department of Gastrointestinal OncologyMoffitt Cancer CenterTampaFlorida
| | | | - Andrew R. Judge
- Department of Physical TherapyUniversity of FloridaGainesvilleFlorida
| | - Jason B. Fleming
- Department of Gastrointestinal OncologyMoffitt Cancer CenterTampaFlorida
| | - Nipun Merchant
- Department of Surgical Oncology, Sylvester Comprehensive Cancer CenterUniversity of Miami Miller School of MedicineMiamiFlorida
| | - Jose G. Trevino
- Department of Surgery, Division of General SurgeryUniversity of Florida Health Sciences CenterGainesvilleFlorida
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Sauvanet A. Gastroenteropancreatic neuroendocrine tumors: Role of surgery. ANNALES D'ENDOCRINOLOGIE 2019; 80:175-181. [PMID: 31079831 DOI: 10.1016/j.ando.2019.04.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Natural history of gastroenteropancreatic (GEP) Neuroendocrine tumors (NETs) is better and better known so indications of surgery are presently selective. Surgical resection, but also endoscopic resection and observation, can be proposed for gastric NETs according to presentation, size and grade. For small bowel NETs, resection is frequently needed but should obtain the best compromise between radicality and postoperative functional disorders. Appendiceal NETs are frequently diagnosed by appendectomy for appendicitis, but some patients at high risk for lymph node metastasis and recurrence should be reoperated for radical resection. Rectal NETs are often diagnosed incidentally; the smallest (<1cm) can be resected endoscopically but the most aggressive need a oncological proctectomy. Pancreatic NETs represent a wide spectrum, ranging from fully benign tumors to very aggressive ones. Insulinomas are mostly benign, responsible for incapacitating symptoms despite medical treatment, and should ideally be treated by parenchyma sparing resection, mainly enucleation. Conversely, symptoms of gastrinomas are efficiently treated medically but their resection needs an oncological approach. Nonfunctioning PNETs are more and more frequently and incidentally discovered. According to their size, presentation and patient's characteristics, they need a resection (oncological or parenchyma-sparing) or a close observation.
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Affiliation(s)
- Alain Sauvanet
- Department of HPB surgery, pôle des maladies de l'appareil digestif (PMAD), université Paris Diderot, hôpital Beaujon, AP-HP, 100, boulevard du Général-Leclerc, 92110 Clichy, France.
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Lawson-Ananissoh LM, Bouglouga O, Bagny A, El-Hadji Yakoubou R, Kaaga L, Redah D. DIGESTIVE DISEASES IN ELDERLY AND FACTORS ASSOCIATED WITH LENGTH OF STAY IN THE HEPATOLOGY AND GASTROENTEROLOGY UNIT OF THE CAMPUS TEACHING HOSPITAL OF LOME (TOGO). ARQUIVOS DE GASTROENTEROLOGIA 2019; 55:369-374. [PMID: 30785520 DOI: 10.1590/s0004-2803.201800000-80] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 09/28/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND The digestive pathologies are frequent in the elderly and often have a latent and atypical symptomatology. OBJECTIVE To assess the epidemiological and evolutionary current data on digestive diseases in the elderly, and look for factors associated with length of hospital stay. METHODS Retrospective study of 10 years, including patients aged 60 and over hospitalized for digestive diseases in the Gastroenterology Department of the Campus Teaching Hospital of Lome, Togo. RESULTS Of 5933 hospitalized patients, there were 1054 patients (17.8%) aged 60 years and over with a digestive pathology (526 men and 528 women). The average age was 69.5 years ±7.9 ranging from 60 to 105 years. The average length of hospital stay was 7.45 days ±6.2 ranging from 1 to 44 days. HIV prevalence was 2.4%. In order of decreasing frequency, there were hepatobiliary pathologies (54.3%) with a predominance of cirrhosis and liver cancer, eso-gastroduodenal pathologies (23.1%) with predominance of ulcers, gastric cancer and esophageal cancer, intestinal pathologies (8.7%) with a predominance of food poisoning, pancreatic pathologies (4.2%) with a predominance of pancreatic cancer and peritoneal pathologies (1.4%). Gastric cancer was the second digestive cancer found after liver cancer. Pancreatic head cancer was the second disease after gastric cancer which need a transfer in a surgical ward (P=0.031). There were 204 deaths (19.4%). The longest duration of hospitalization was due to gastric cancer (9.16 days). CONCLUSION Hepatobiliary diseases were the most frequent and associated with a high death rate and a long hospital stay.
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Affiliation(s)
| | - Oumboma Bouglouga
- Hepatology and Gastroenterology Unit of the Campus Teaching Hospital of Lome, Togo
| | - Aklesso Bagny
- Hepatology and Gastroenterology Unit of the Campus Teaching Hospital of Lome, Togo
| | | | - Laconi Kaaga
- Hepatology and Gastroenterology Unit of the Campus Teaching Hospital of Lome, Togo
| | - Datouda Redah
- Hepatology and Gastroenterology Unit of the Campus Teaching Hospital of Lome, Togo
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28
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Perrotta de Souza LM, Moreira JP, Fogaça HS, Eulálio JMR, Luiz RR, de Souza HS. Increasing pancreatic cancer is not paralleled by pancreaticoduodenectomy volumes in Brazil: A time trend analysis. Hepatobiliary Pancreat Dis Int 2019; 18:79-86. [PMID: 30583855 DOI: 10.1016/j.hbpd.2018.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 12/04/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Currently, surgical resection represents the only curative treatment for pancreatic cancer (PC), however, the majority of tumors are no longer resectable by the time of diagnosis. The aim of this study was to describe time trends and distribution of pancreaticoduodenectomies (PDs) performed for treating PC in Brazil in recent years. METHODS Data were retrospectively obtained from Brazilian Health Public System (namely DATASUS) regarding hospitalizations for PC and PD in Brazil from January 2008 to December 2015. PC and PD rates and their mortalities were estimated from DATASUS hospitalizations and analyzed for age, gender and demographic characteristics. RESULTS A total of 2364 PDs were retrieved. Albeit PC incidence more than doubled, the number of PDs increased only 37%. Most PDs were performed in men (52.2%) and patients between 50 and 69 years old (59.5%). Patients not surgically treated and those 70 years or older had the highest in-hospital mortality rates. The most developed regions (Southeast and South) as well as large metropolitan integrated municipalities registered 76.2% and 54.8% of the procedures, respectively. LMIM PD mortality fluctuated, ranging from 13.6% in 2008 to 11.8% in 2015. CONCLUSIONS This study suggests a trend towards regionalization and volume-outcome relationships for PD due to PC, as large metropolitan integrated municipalities registered most of the PDs and more stable mortality rates. The substantial differences between PD and PC increasing rates reveals a limiting step on the health system resoluteness. Reduction in the number of hospital beds and late access to hospitalization, despite improvement in diagnostic methods, could at least in part explain these findings.
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Affiliation(s)
- Lucila M Perrotta de Souza
- Department of Internal Medicine, School of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Jessica Pl Moreira
- Institute of Public Health Studies (IESC), Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Homero S Fogaça
- Department of Internal Medicine, School of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - José Marcus Raso Eulálio
- Department of Surgery, School of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Ronir R Luiz
- Institute of Public Health Studies (IESC), Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Heitor Sp de Souza
- Department of Internal Medicine, School of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; D'Or Institute for Research and Education, Rio de Janeiro, Brazil.
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Bateni SB, Olson JL, Hoch JS, Canter RJ, Bold RJ. Drivers of Cost for Pancreatic Surgery: It's Not About Hospital Volume. Ann Surg Oncol 2018; 25:3804-3811. [PMID: 30218244 DOI: 10.1245/s10434-018-6758-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Outcomes for pancreatic resection have been studied extensively due to the high morbidity and mortality rates, with high-volume centers achieving superior outcomes. Ongoing investigations include healthcare costs, given the national focus on reducing expenditures. Therefore, we sought to evaluate the relationships between pancreatic surgery costs with perioperative outcomes and volume status. METHODS We performed a retrospective analysis of 27,653 patients who underwent elective pancreatic resections from October 2013 to June 2017 using the Vizient database. Costs were calculated from charges using cost-charge ratios and adjusted for geographic variation. Generalized linear modeling adjusting for demographic, clinical, and operation characteristics was performed to assess the relationships between cost and length of stay, complications, in-hospital mortality, readmissions, and hospital volume. High-volume centers were defined as hospitals performing ≥ 19 operations annually. RESULTS The unadjusted mean cost for pancreatic resection and corresponding hospitalization was $20,352. There were no differences in mean costs for pancreatectomies performed at high- and low-volume centers [- $1175, 95% confidence interval (CI) - $3254 to $904, p = 0.27]. In subgroup analysis comparing adjusted mean costs at high- and low-volume centers, there was no difference among patients without an adverse outcome (- $99, 95% CI - $1612 to 1414, p = 0.90), one or more adverse outcomes (- $1586, 95% CI - $4771 to 1599, p = 0.33), or one or more complications (- $2835, 95% CI - $7588 to 1919, p = 0.24). CONCLUSIONS While high-volume hospitals have fewer adverse outcomes, there is no relationship between surgical volume and costs, which suggests that, in itself, surgical volume is not an indicator of improved healthcare efficiency reflected by lower costs. Patient referral to high-volume centers may not reduce overall healthcare expenditures for pancreatic operations.
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Affiliation(s)
- Sarah B Bateni
- Divison of Surgical Oncology, Suite 3010, Department of Surgery, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Jennifer L Olson
- Divison of Surgical Oncology, Suite 3010, Department of Surgery, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Jeffrey S Hoch
- Center for Healthcare Policy and Research, University of California, Davis, Sacramento, CA, USA
| | - Robert J Canter
- Divison of Surgical Oncology, Suite 3010, Department of Surgery, University of California, Davis Medical Center, Sacramento, CA, USA
| | - Richard J Bold
- Divison of Surgical Oncology, Suite 3010, Department of Surgery, University of California, Davis Medical Center, Sacramento, CA, USA.
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Abstract
This article begins by introducing the historical background surrounding the volume-outcomes relationship literature, particularly in complex cancer surgery. The state of evidence surrounding mortality, as well as other outcomes, in relation to both hospital and surgeon procedure volume is synthesized. Where it is understood, the level of adoption of regionalization of various complex surgeries in the United States is also presented. Various controversies are weighed and discussed. Finally, various models of regionalization and proposed alternatives to regionalization from the peer-reviewed literature are presented.
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Affiliation(s)
- Stephanie Lumpkin
- Department of Surgery, University of North Carolina, Chapel Hill, NC 27514, USA
| | - Karyn Stitzenberg
- Department of Surgery, University of North Carolina, Chapel Hill, NC 27514, USA.
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What Are the Most Significant Cost and Value Drivers for Pancreatic Resection in an Integrated Healthcare System? J Am Coll Surg 2018; 227:45-53. [PMID: 29580880 DOI: 10.1016/j.jamcollsurg.2018.02.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 02/15/2018] [Accepted: 02/17/2018] [Indexed: 11/22/2022]
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Lindeman B, Hashimoto DA, Bababekov YJ, Stapleton SM, Chang DC, Hodin RA, Phitayakorn R. Fifteen years of adrenalectomies: impact of specialty training and operative volume. Surgery 2018; 163:150-156. [PMID: 29128168 PMCID: PMC5903575 DOI: 10.1016/j.surg.2017.05.024] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 04/24/2017] [Accepted: 05/21/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Previous associations between surgeon volume with adrenalectomy outcomes examined only a sample of procedures. We performed an analysis of all adrenalectomies performed in New York state to assess the effect of surgeon volume and specialty on clinical outcomes. METHODS Adrenalectomies performed in adults were identified from the New York Statewide Planning and Research Cooperative System from 2000-2014. Surgeon specialty, volume, and patient demographics were assessed. High volume was defined using a significance threshold at ≥4 adrenalectomies per year. Outcome variables included in-hospital mortality, duration of stay, and in-hospital complications. RESULTS A total of 6,054 adrenalectomies were included. Median patient age was 56 years; 41.9% were men and 68.3% were white. Urologists (n = 462) performed 46.8% of adrenalectomies, general surgeons (n = 599) performed 35.0%, and endocrine surgeons (n = 23) performed 18.1%. Significantly more endocrine surgeons were high-volume compared with urologists and general surgeons (65.2% vs 10.2% and 6.7%, respectively, P < .001). High-volume surgeons had significantly lower mortality compared with low-volume surgeons (0.56% vs 1.25%, P = .004) and a lower rate of complications (10.2% vs 16.4%, P = < .001). Endocrine surgeons were more likely to perform laparoscopic procedures (34.8% vs 22.4% general surgeons and 27.7% US, P < .001) and had the lowest median hospital duration of stay (2 days vs 4 days general surgeons and 3 days urologists, P < .001). After risk adjustment, low surgeon volume was an independent predictor of inpatient complications (odds ratio = 0.96, P = .002). CONCLUSION Patients with adrenal disease should be referred to surgeons based on adrenalectomy volume regardless of specialty, but most endocrine surgeons that perform adrenalectomy are high-volume for the procedure.
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Affiliation(s)
| | | | - Yanik J Bababekov
- Department of Surgery, Massachusetts General Hospital, Boston, MA; Codman Center for Surgery and Outcomes Research, Massachusetts General Hospital, Boston, MA
| | - Sahael M Stapleton
- Department of Surgery, Massachusetts General Hospital, Boston, MA; Codman Center for Surgery and Outcomes Research, Massachusetts General Hospital, Boston, MA
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Boston, MA; Codman Center for Surgery and Outcomes Research, Massachusetts General Hospital, Boston, MA
| | - Richard A Hodin
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Roy Phitayakorn
- Department of Surgery, Massachusetts General Hospital, Boston, MA.
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Altieri MS, Yang J, Groves D, Yin D, Cagino K, Talamini M, Pryor A. Academic status does not affect outcome following complex hepato-pancreato-biliary procedures. Surg Endosc 2017; 32:2355-2364. [DOI: 10.1007/s00464-017-5931-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Accepted: 10/08/2017] [Indexed: 02/07/2023]
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Cerullo M, Chen SY, Dillhoff M, Schmidt C, Canner JK, Pawlik TM. Association of Hospital Market Concentration With Costs of Complex Hepatopancreaticobiliary Surgery. JAMA Surg 2017; 152:e172158. [PMID: 28746714 PMCID: PMC5831444 DOI: 10.1001/jamasurg.2017.2158] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Accepted: 04/09/2017] [Indexed: 12/26/2022]
Abstract
IMPORTANCE Trade-offs involved with market competition, overall costs to payers and consumers, and quality of care have not been well defined. Less competition within any given market may enable provider-driven increases in charges. OBJECTIVE To examine the association between regional hospital market concentration and hospital charges for hepatopancreaticobiliary surgical procedures. DESIGN, SETTING, AND PARTICIPANTS This study included all patients undergoing hepatic or pancreatic resection in the Nationwide Inpatient Sample from January 1, 2003, through December 31, 2011. Hospital market concentration was assessed using a variable-radius Herfindahl-Hirschman Index (HHI) in the 2003, 2006, and 2009 Hospital Market Structure files. Data were analyzed from November 19, 2016, through March 2, 2017. INTERVENTIONS Hepatic or pancreatic resection. MAIN OUTCOMES AND MEASURES Multivariable mixed-effects log-linear models were constructed to determine the association between HHI and total costs and charges for hepatic or pancreatic resection. RESULTS Weighted totals of 38 711 patients undergoing pancreatic resection (50.8% men and 49.2% women; median age, 65 years [interquartile range, 55-73 years]) and 52 284 patients undergoing hepatic resection (46.8% men and 53.2% women; median age, 59 years [interquartile range, 49-69 years]) were identified. Higher institutional volume was associated with lower cost of pancreatic resection (-5.4%; 95% CI, -10.0% to -0.5%; P = .03) and higher cost of hepatic resection (13.4%; 95% CI, 8.2% to 18.8%; P < .001). For pancreatic resections, costs were 5.5% higher (95% CI, 0.1% to 11.1%; P = .047) in unconcentrated hospital markets relative to moderately concentrated markets, although overall charges were 8.3% lower (95% CI, -14.0% to -2.3%; P = .008) in highly concentrated markets. For hepatic resections, hospitals in highly concentrated markets had 8.4% lower costs (95% CI, -13.0% to -3.6%; P = .001) compared with those in unconcentrated markets and charges that were 13.4% lower (95% CI, -19.3% to -7.1%; P < .001) compared with moderately concentrated markets and 10.5% lower (95% CI, -16.2% to -4.4%; P = .001) compared with unconcentrated markets. CONCLUSIONS AND RELEVANCE Higher market concentration was associated with lower overall charges and lower costs of pancreatic and hepatic surgery. For complex, highly specialized procedures, hospital market consolidation may represent the best value proposition: better quality of care with lower costs.
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Affiliation(s)
- Marcelo Cerullo
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sophia Y. Chen
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mary Dillhoff
- Department of Surgery, Wexner Medical Center at The Ohio State University, Columbus
| | - Carl Schmidt
- Department of Surgery, Wexner Medical Center at The Ohio State University, Columbus
| | - Joseph K. Canner
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Timothy M. Pawlik
- Department of Surgery, Wexner Medical Center at The Ohio State University, Columbus
- Deputy Editor, JAMA Surgery
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Rosemurgy AS, Downs DJ, Swaid F, Ryan CE, Smart AE, Spence JD, Ross SB. Regional differences for pancreaticoduodenectomy in Florida: Location matters. Am J Surg 2017; 214:862-870. [PMID: 28760357 DOI: 10.1016/j.amjsurg.2017.07.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Revised: 06/27/2017] [Accepted: 07/03/2017] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Regionalization of care raises potential for differences in cost of care and outcome. This study was undertaken to determine if costs and outcome after pancreaticoduodenectomy vary by region in Florida, and whether costs and outcome are related. METHODS Inpatient data for pancreaticoduodenectomy in Florida during 2010-2012 were obtained from the Florida Agency for Health Care Administration. Seven geographically different regions were designated based on "cost of living index" and "urban to rural population ratio". Hospital costs, LOS, in-hospital mortality, and the frequency with which surgeons performed pancreaticoduodenectomy were evaluated for these regions. RESULTS Median hospital costs for pancreaticoduodenectomy by region ranged from $101,436-$214,971. Median hospital costs by region correlated positively with LOS (p < 0.0001) and in-hospital mortality (p < 0.0001), and negatively with the frequency of pancreaticoduodenectomies performed by high-volume surgeons (p < 0.0001). CONCLUSIONS There are regional differences for hospital costs and outcome with pancreaticoduodenectomy in Florida. Regions with lower costs had more pancreaticoduodenectomies performed by high-volume surgeons, shorter LOS, and lower in-hospital mortality rates. Regional differences in cost and quality-of-care need to be studied and abrogated to provide uniform optimal care.
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Affiliation(s)
- Alexander S Rosemurgy
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive & Robotic Surgery, Florida Hospital Tampa, Tampa, FL, USA.
| | - Darrell J Downs
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive & Robotic Surgery, Florida Hospital Tampa, Tampa, FL, USA
| | - Forat Swaid
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive & Robotic Surgery, Florida Hospital Tampa, Tampa, FL, USA
| | - Carrie E Ryan
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive & Robotic Surgery, Florida Hospital Tampa, Tampa, FL, USA
| | - Amanda E Smart
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive & Robotic Surgery, Florida Hospital Tampa, Tampa, FL, USA
| | - Janelle D Spence
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive & Robotic Surgery, Florida Hospital Tampa, Tampa, FL, USA
| | - Sharona B Ross
- Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive & Robotic Surgery, Florida Hospital Tampa, Tampa, FL, USA
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Dhayat SA, Mirgorod P, Lenschow C, Senninger N, Anthoni C, Vowinkel T. Challenges in pancreatic adenocarcinoma surgery - National survey and current practice guidelines. PLoS One 2017; 12:e0173374. [PMID: 28267771 PMCID: PMC5340358 DOI: 10.1371/journal.pone.0173374] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 02/20/2017] [Indexed: 01/05/2023] Open
Abstract
Background Pancreatic ductal adenocarcinoma (PDAC) remains one of the most deadly cancers in Europe and the USA. There is consensus that radical tumor surgery is the only viable option for any long-term survival in patients with PDAC. So far, limited data are available regarding the routine surgical management of patients with advanced PDAC in the light of surgical guidelines. Methods A national survey on perioperative management of patients with PDAC and currently applied criteria on their tumor resectability in German university and community hospitals was carried out. Results With a response rate of 81.6% (231/283) a total of 95 (41.1%) participating departments practicing pancreatic surgery in Germany are certified as competence and reference centers for surgical diseases of the pancreas in 2016. More than 95% of them indicate to carry out structured and interdisciplinary therapies along with an interdisciplinary pre- and postoperative tumor board. The majority of survey respondents prefer the pylorus-preserving partial pancreatoduodenectomy (93.1%) with standard lymphadenectomy for cancer of the pancreatic head. Intraoperative histological evaluation of the resection margins is used regularly by 99% of the survey respondents. 98.7% of survey respondents carry out partial or complete vein resection, 126 respondents (54.5%) would resect tumor adjacent arteries, and 102 respondents (44.2%) would perform metastasectomy if complete PDAC resection (R0) is possible. Conclusion Evidence-based and standardized pancreatic surgery is practiced by a large number of hospitals in Germany. However, a significant number of survey respondents support an extended radical tumor resection in patients with advanced PDAC even when not indicated by current clinical guidelines.
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Affiliation(s)
- Sameer A. Dhayat
- Department of General and Visceral Surgery, University Hospital Muenster, Muenster, Germany
- * E-mail:
| | - Philip Mirgorod
- Department of General and Visceral Surgery, University Hospital Muenster, Muenster, Germany
| | - Christina Lenschow
- Department of General and Visceral Surgery, University Hospital Muenster, Muenster, Germany
| | - Norbert Senninger
- Department of General and Visceral Surgery, University Hospital Muenster, Muenster, Germany
| | - Christoph Anthoni
- Department of General and Visceral Surgery, University Hospital Muenster, Muenster, Germany
| | - Thorsten Vowinkel
- Department of General and Visceral Surgery, University Hospital Muenster, Muenster, Germany
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Søreide JA, Sandvik OM, Søreide K. Improving pancreas surgery over time: Performance factors related to transition of care and patient volume. Int J Surg 2016; 32:116-22. [PMID: 27373194 DOI: 10.1016/j.ijsu.2016.06.046] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 05/20/2016] [Accepted: 06/26/2016] [Indexed: 01/02/2023]
Abstract
BACKGROUND Pancreas surgery has evolved with better diagnostic imaging, changing indications, and improved patient selection. Outside high-volume tertiary centers, the documented effect of evolution in care and volumes are limited. Thus, we aimed to review indications and outcomes in pancreas surgery during the transition from community-based hospital to a university hospital. METHODS All pancreatic surgeries performed between 1986 and 2012 within a well-defined Norwegian population were identified from the hospital's database. Indications and postoperative outcomes, including mortality, were investigated. RESULTS Of the 219 included patients (54% males; median age, 64 years), 150 (69%) underwent pancreatoduodenectomy; 55 (25%), distal resection; and 5 (2%), enucleation. The annual number of operations increased during the study period (from <10/yr to >20/yr). Most patients (169; 77%) underwent surgery for suspected malignancy. The 30-day mortality decreased significantly over time among patients treated for pancreatic cancer (from 16.1% to 3.5%; p = 0.012). Over time, significant reductions in median hospitalization time (19 versus 12 days; p < 0.001), re-operation rate (37.1% versus 8.4%; p < 0.001), and median ICU stay (3 versus 0 days; p < 0.001) were observed. CONCLUSION The transition to university hospital and increase in volume has led to significant improvements in several performance metrics and reduced postoperative mortality. We believe improved perioperative management and focused, multidisciplinary care-bundles to be of importance.
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Affiliation(s)
- Jon Arne Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Oddvar M Sandvik
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Effect of Hospital Volume on Surgical Outcomes After Pancreaticoduodenectomy: A Systematic Review and Meta-analysis. Ann Surg 2016; 263:664-72. [PMID: 26636243 DOI: 10.1097/sla.0000000000001437] [Citation(s) in RCA: 208] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The aim of the study was to evaluate the relationship between hospital volume and outcome after pancreaticoduodenectomy (PD). SUMMARY BACKGROUND DATA Previous reviews for the hospital volume-outcome relationship after pancreatic resection were limited owing to clinical or methodological heterogeneity, resulting from differences in surgical procedures and high-volume hospital (HVH) definitions across studies. METHODS We conducted a rigorous meta-analysis on the influence of hospital volume on various outcomes after PD using strict inclusion criteria and single cutoff values for HVHs. RESULTS Thirteen studies based on nationwide databases from 11 countries, and including 58,023 patients in total, were included in this study. The overall pooled odds ratio (OR) for mortality favoring the HVH group was 2.37 [95% confidence interval (CI): 1.95-2.88] with high heterogeneity (I = 63%). We therefore classified all included studies into categories according to the cutoff values for HVH as defined in each individual study. The pooled OR for each category of 1 to 19, 20 to 29, and ≥30 PDs per year was 1.94, 2.34, and 4.05, respectively. There were significant differences among these categories (I = 58.9%, P = 0.09). The 2 former categories showed no statistical interstudy heterogeneities. The data did not suggest publication bias. These trends persisted in all subgroup analyses. Postoperative length of stay in the HVH group was significantly shorter with mild interstudy heterogeneity. CONCLUSIONS This meta-analysis included studies from different countries with disparate health care systems and provided strong evidence for an inverse association between higher hospital volume and lower mortality after PD. Variations in HVH cutoff values across studies majorly influenced the overall heterogeneity.
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Fong ZV, Chang DC, Ferrone CR, Lillemoe KD, Fernandez del Castillo C. Early National Experience with Laparoscopic Pancreaticoduodenectomy for Ductal Adenocarcinoma: Is This Really a Short Learning Curve? J Am Coll Surg 2016; 222:209. [DOI: 10.1016/j.jamcollsurg.2015.11.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 11/04/2015] [Indexed: 11/29/2022]
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Higuera O, Ghanem I, Nasimi R, Prieto I, Koren L, Feliu J. Management of pancreatic cancer in the elderly. World J Gastroenterol 2016; 22:764-75. [PMID: 26811623 PMCID: PMC4716075 DOI: 10.3748/wjg.v22.i2.764] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 10/03/2015] [Accepted: 11/09/2015] [Indexed: 02/06/2023] Open
Abstract
Currently, pancreatic adenocarcinoma mainly occurs after 60 years of age, and its prognosis remains poor despite modest improvements in recent decades. The aging of the population will result in a rise in the incidence of pancreatic adenocarcinoma within the next years. Thus, the management of pancreatic cancer in the elderly population is gaining increasing relevance. Older cancer patients represent a heterogeneous group with different biological, functional and psychosocial characteristics that can modify the usual management of this disease, including pharmacokinetic and pharmacodynamic changes, polypharmacy, performance status, comorbidities and organ dysfunction. However, the biological age, not the chronological age, of the patient should be the limiting factor in determining the most appropriate treatment for these patients. Unfortunately, despite the increased incidence of this pathology in older patients, there is an underrepresentation of these patients in clinical trials, and the management of older patients is thus determined by extrapolation from the results of studies performed in younger patients. In this review, the special characteristics of the elderly, the multidisciplinary management of localized and advanced ductal adenocarcinoma of the pancreas and the most recent advances in the management of this condition will be discussed, focusing on surgery, chemotherapy, radiation and palliative care.
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Tran TB, Dua MM, Worhunsky DJ, Poultsides GA, Norton JA, Visser BC. An economic analysis of pancreaticoduodenectomy: should costs drive consumer decisions? Am J Surg 2016; 211:991-997.e1. [PMID: 26902956 DOI: 10.1016/j.amjsurg.2015.10.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 10/10/2015] [Accepted: 10/28/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Consumer groups campaign for cost transparency believing that patients will select hospitals accordingly. We sought to determine whether the cost of pancreaticoduodenectomy (PD) should be considered in choosing a hospital. METHODS Using the Nationwide Inpatient Sample database, we analyzed charges for patients who underwent PD from 2000 to 2010. Outcomes were stratified by hospital volume. RESULTS A total of 15,599 PDs were performed in 1,186 hospitals. The median cost was $87,444 (interquartile range $16,015 to $144,869). High volume hospitals (HVH) had shorter hospital stay (11 vs 15 days, P < .001) and mortality (3% vs 7.6%, P < .001). PD performed at low volume hospitals had higher charges compared with HVH ($97,923 vs $81,581, P < .001). On multivariate analysis, HVH was associated with a lower risk of mortality, while extremes in hospital costs, cardiac comorbidity, and any complication were significant predictors of mortality. CONCLUSION Although PDs performed at HVH are associated with better outcomes and lower hospital charges, costs should not be the primary determinant when selecting a hospital.
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Affiliation(s)
- Thuy B Tran
- Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Suite H3680D, Stanford, CA 94305, USA
| | - Monica M Dua
- Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Suite H3680D, Stanford, CA 94305, USA
| | - David J Worhunsky
- Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Suite H3680D, Stanford, CA 94305, USA
| | - George A Poultsides
- Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Suite H3680D, Stanford, CA 94305, USA
| | - Jeffrey A Norton
- Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Suite H3680D, Stanford, CA 94305, USA
| | - Brendan C Visser
- Division of Surgical Oncology, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Suite H3680D, Stanford, CA 94305, USA.
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Tran TB, Dua MM, Worhunsky DJ, Poultsides GA, Norton JA, Visser BC. The First Decade of Laparoscopic Pancreaticoduodenectomy in the United States: Costs and Outcomes Using the Nationwide Inpatient Sample. Surg Endosc 2015; 30:1778-83. [PMID: 26275542 DOI: 10.1007/s00464-015-4444-y] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Accepted: 07/13/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND Minimally invasive pancreaticoduodenectomy (PD) remains an uncommon procedure, and the safety and efficacy remain uncertain beyond single institution case series. The aim of this study is to compare outcomes and costs between laparoscopic (LPD) and open PD (OPD) using a large population-based database. METHODS The Nationwide Inpatient Sample database (a sample of approximately 20 % of all hospital discharges) was analyzed to identify patients who underwent PD from 2000 to 2010. Patient demographics, comorbidities, hospital characteristics, inflation-adjusted total charges, and complications were evaluated using univariate and multivariate logistic regression. Hospitals were categorized as high-volume hospitals (HVH) if more than 20 PD (open and laparoscopic) were performed annually, while those performing fewer than 20 PD were classified as low-volume hospitals. RESULTS Of the 15,574 PD identified, 681 cases were LPD (4.4 %). Compared to OPD, patients who underwent LPD were slightly older (65 vs. 67 years; p = 0.001) and were more commonly treated at HVH (56.6 vs. 66.1 %; p < 0.001). Higher rates of complications were observed in OPD than LPD (46 vs. 39.4 %; p = 0.001), though mortality rates were comparable (5 vs. 3.8 %, p = 0.27). Inflation-adjusted median hospital charges were similar between OPD and LPD ($87,577 vs. $81,833, p = 0.199). However, hospital stay was slightly longer in the OPD group compared to LPD group (12 vs. 11 days, p < 0.001). Stratifying outcomes by hospital volume, LPD at HVH resulted in shorter hospital stays (9 vs. 13 days, p < 0.001), which translated into significantly lower median hospital charges ($76,572 vs. $106,367, p < 0.001). CONCLUSIONS Contrary to fears regarding the potential for compromised outcomes early in the learning curve, LPD morbidity in its first decade is modestly reduced, while hospital costs are comparable to OPD. In high-volume pancreatic hospitals, LPD is associated with a reduction in length of stay and hospital costs.
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Affiliation(s)
- Thuy B Tran
- Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Suite H3680D, Stanford, CA, 94305, USA
| | - Monica M Dua
- Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Suite H3680D, Stanford, CA, 94305, USA
| | - David J Worhunsky
- Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Suite H3680D, Stanford, CA, 94305, USA
| | - George A Poultsides
- Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Suite H3680D, Stanford, CA, 94305, USA
| | - Jeffrey A Norton
- Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Suite H3680D, Stanford, CA, 94305, USA
| | - Brendan C Visser
- Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Suite H3680D, Stanford, CA, 94305, USA.
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Shimatani M, Takaoka M, Tokuhara M, Miyoshi H, Ikeura T, Okazaki K. Review of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography using several endoscopic methods in patients with surgically altered gastrointestinal anatomy. World J Gastrointest Endosc 2015; 7:617-627. [PMID: 26078830 PMCID: PMC4461936 DOI: 10.4253/wjge.v7.i6.617] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 01/14/2015] [Accepted: 03/09/2015] [Indexed: 02/05/2023] Open
Abstract
The endoscopic approach for biliary diseases in patients with surgically altered gastrointestinal anatomy (SAGA) had been generally deemed impractical. However, it was radically made feasible by the introduction of double balloon endoscopy (DBE) that was originally developed for diagnosis and treatments for small-bowel diseases. Followed by the subsequent development of single-balloon endoscopy (SBE) and spiral endoscopy (SE), interventions using several endoscopes for biliary disease in patients with SAGA widely gained an acceptance as a new modality. Many studies have been made on this new technique. Yet, some problems are to be solved. For instance, the mutual unavailability among devices due to different working lengths and channels, and unestablished standardization of procedural techniques can be raised. Additionally, in an attempt to standardize endoscopic procedures, it is important to evaluate biliary cannulating methods by case with existence of papilla or not. A full comprehension of the features of respective scope types is also required. However there are not many papers written as a review. In our manuscript, we would like to evaluate and make a review of the present status of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography applying DBE, SBE and SE for biliary diseases in patients with SAGA for establishment of these modalities as a new technology and further improvement of the scopes and devices.
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Delayed gastric emptying after pancreaticoduodenectomy. Risk factors, predictors of severity and outcome. A single center experience of 588 cases. J Gastrointest Surg 2015; 19:1093-100. [PMID: 25759078 DOI: 10.1007/s11605-015-2795-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 03/02/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is a common complication after pancreaticoduodenectomy (PD). This study was designed to evaluate perioperative risk variables for DGE after PD and analyze the factors that predict its severity. PATIENTS AND METHOD Demographic data, preoperative, intraoperative, and postoperative variables were collected. RESULTS A total of 588 consecutive patients underwent PD. One hundred and five patients (17.9 %) developed DGE of any type. Forty-three patients (7.3 %) had a type A, 53 patients (9.01 %) had DGE type B, and the remaining nine patients (1.5 %) had DGE type C. BMI > 25, diabetes mellitus (DM), preoperative biliary drainage, retrocolic reconstruction, type of pancreatic reconstruction, presence of complications, postoperative pancreatic fistula (POPF), and bile leaks were significantly associated with a higher incidence of DGE. Thirty-three (31.4 %) patients were diagnosed as primary DGE, while 72 (68.5 %) patients had DGE secondary to concomitant complications. Type B and C DGE were significantly noticed in secondary DGE (P = 0.04). Hospital stay was significantly shorter in primary DGE. CONCLUSION Retrocolic GJ, DM, presence of complications, type of pancreatic reconstruction, and severity of POPF were independent significant risk factors for development of DGE. Type B and C DGE were significantly more in secondary DGE.
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Bliss LA, Yang CJ, Chau Z, Ng SC, McFadden DW, Kent TS, Moser AJ, Callery MP, Tseng JF. Patient selection and the volume effect in pancreatic surgery: unequal benefits? HPB (Oxford) 2014; 16:899-906. [PMID: 24905343 PMCID: PMC4238856 DOI: 10.1111/hpb.12283] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 05/01/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND The volume effect in pancreatic surgery is well established. Regionalization to high-volume centres has been proposed. The effect of this proposal on practice patterns is unknown. METHODS Retrospective review of pancreatectomy patients in the Nationwide Inpatient Sample 2004-2011. Inpatient mortality and complication rates were calculated. Patients were stratified by annual centre pancreatic resection volume (low <5, medium 5-18, high >18). Multivariable regression model evaluated predictors of resection at a high-volume centre. RESULTS In total, 129,609 patients underwent a pancreatectomy. The crude inpatient mortality rate was 4.3%. 36.0% experienced complications. 66.5% underwent a resection at high-volume centres. In 2004, low-, medium- and high-volume centres resected 16.3%, 24.5% and 59.2% of patients, compared with 7.6%, 19.3% and 73.1% in 2011. High-volume centres had lower mortality (P < 0.001), fewer complications (P < 0.001) and a shorter median length of stay (P < 0.001). Patients at non-high-volume centres had more comorbidities (P = 0.001), lower rates of private insurance (P < 0.001) and more non-elective admissions (P < 0.001). DISCUSSION In spite of a shift to high-volume hospitals, a substantial cohort still receives a resection outside of these centres. Patients receiving non-high-volume care demonstrate less favourable comorbidities, insurance and urgency of operation. The implications are twofold: already disadvantaged patients may not benefit from the high-volume effect; and patients predisposed to do well may contribute to observed superior outcomes at high-volume centres.
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Affiliation(s)
- Lindsay A Bliss
- Surgical Outcomes Analysis & Research and Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical SchoolBoston, MA, USA,Department of Surgery, University of Connecticut Health Center, University of Connecticut School of MedicineFarmington, CT, USA
| | - Catherine J Yang
- Surgical Outcomes Analysis & Research and Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical SchoolBoston, MA, USA
| | - Zeling Chau
- Department of Surgery, UMass Memorial Medical Center, University of Massachusetts Medical SchoolWorcester, MA, USA
| | - Sing Chau Ng
- Surgical Outcomes Analysis & Research and Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical SchoolBoston, MA, USA
| | - David W McFadden
- Department of Surgery, University of Connecticut Health Center, University of Connecticut School of MedicineFarmington, CT, USA
| | - Tara S Kent
- Surgical Outcomes Analysis & Research and Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical SchoolBoston, MA, USA
| | - A James Moser
- Surgical Outcomes Analysis & Research and Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical SchoolBoston, MA, USA
| | - Mark P Callery
- Surgical Outcomes Analysis & Research and Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical SchoolBoston, MA, USA
| | - Jennifer F Tseng
- Surgical Outcomes Analysis & Research and Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical SchoolBoston, MA, USA,Correspondence: Jennifer F. Tseng, Division of Surgical Oncology, Clinical Co-Director for Surgery, BIDMC Cancer Center, Harvard Medical School, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Stoneman 9, Boston, MA 02215, USA. Tel: +1 617 667 3746. Fax: +1 617 667 2792. E-mail:
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Hore T, Thomas M, Brown L, Sakowska M, Connor S. Is there an alternative to centralization for pancreatic resection in New Zealand? ANZ J Surg 2014; 86:332-6. [PMID: 24846497 DOI: 10.1111/ans.12688] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Internationally pancreatic surgery has become increasingly centralized; however, geographical and population distribution within New Zealand (NZ) limits the practicalities of such an approach. The aim of this study was to review the short-term outcomes of patients undergoing pancreatic surgery by a single hepato-pancreato-biliary trained surgeon in a centre that would meet the minimum criteria set by the NZ National Standards but not necessarily the definition of a high-volume surgeon/centre. METHODS A retrospective review of consecutive patients undergoing pancreatic resection within an enhanced recovery programme by a single surgeon between March 2005 and April 2013. Primary outcomes were 30-day morbidity and 90-day mortality. RESULTS A total of 156 patients who underwent a pancreatic resection were included. Eighty-two (53%) patients underwent a pancreaticoduodenectomy. Forty-seven (30%) underwent a left pancreatectomy. Overall, 30-day morbidity was 64% and overall 90-day mortality was 2.6%. Overall median length of stay was 11 (3-140) days. CONCLUSIONS Acceptable outcomes have been achieved for patients undergoing pancreatic resection within a centre that meets the criteria proposed by the NZ National Standards for treatment of pancreatic cancer.
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Affiliation(s)
- Todd Hore
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Megan Thomas
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Lisa Brown
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Magdalena Sakowska
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Saxon Connor
- Department of General Surgery, Christchurch Hospital, Christchurch, New Zealand
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Shimatani M, Takaoka M, Matsushita M, Okazaki K. Endoscopic approaches for pancreatobiliary diseases in patients with altered gastrointestinal anatomy. Dig Endosc 2014; 26 Suppl 1:70-8. [PMID: 24118126 DOI: 10.1111/den.12175] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Accepted: 08/16/2013] [Indexed: 12/11/2022]
Abstract
Endoscopic treatment for pancreatobiliary diseases is less invasive than surgery and percutaneous transhepatic biliary drainage is highly beneficial to patients. The endoscopic approach is indicated for an increasing number of patients, including those who have undergone previous gastrointestinal surgery, although these patients face two major challenges. First, the endoscopic approach to the afferent loop, blind end, and the site of choledochojejunostomy is difficult with the use of a conventional endoscope because of the distance from the gastrojejunal anastomosis site, unusual anatomical features of the intestine such as its winding shape, and postoperative adhesion. Second, it is difficult to reach Vater's papilla or the site of choledochojejunostomy and to cannulate selectively into the pancreatic and/or biliary duct. The balloon-assisted endoscope (BAE), a recently developed technology, can be useful for carrying out endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy. ERCP using the BAE is highly effective and safe in patients with altered gastrointestinal anatomy, especially in patients with Roux-en-Y reconstruction.
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Affiliation(s)
- Masaaki Shimatani
- Third Department of Internal Medicine, Kansai Medical University, Hirakata, Japan
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Complications nearly double the cost of care after pancreaticoduodenectomy. Am J Surg 2012; 204:332-8. [DOI: 10.1016/j.amjsurg.2011.10.019] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Revised: 10/13/2011] [Accepted: 10/13/2011] [Indexed: 12/25/2022]
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Treatment of pancreatic and periampullary cancers at a community hospital: successful application of tertiary care treatment standards. Int J Surg Oncol 2011; 2011:936516. [PMID: 22312532 PMCID: PMC3263692 DOI: 10.1155/2011/936516] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2011] [Accepted: 09/21/2011] [Indexed: 11/17/2022] Open
Abstract
Background. The treatment of pancreatic cancer and other periampullary neoplasms is complex and challenging. Major high-volume cancer centers can provide excellent multidisciplinary care of these patients but almost two-thirds of pancreatic cancer patients are treated at low volume centers. There is very little published data from low volume community cancer programs in regards to the treatment of periampullary cancer. In this study, a review of comprehensive periampullary cancer care at two low volume hospitals with comparison to national standards is presented. Methods. This is a retrospective review of 70 consecutive patients with periampullary neoplasms who underwent surgery over a 5-year period (2006–2010) at two community hospitals. Results. There were 51 successful resections of 70 explorations (73%) including 34 Whipple procedures. Mortality rate was 2.9%. Comparison of these patients to national standards was made in terms of operative mortality, resectability rate, administration of adjuvant therapy, clinical trial participation and overall survival. The results in these patients were comparable to national standards. Conclusions. With adequate commitment of resources and experienced surgical and oncologic practitioners, community cancer centers can meet national tertiary care standards in terms of pancreatic and periampullary cancer care.
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[Adrenal surgery in Spain: final results of a national survey]. Cir Esp 2011; 89:663-9. [PMID: 21907334 DOI: 10.1016/j.ciresp.2011.07.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Revised: 06/27/2011] [Accepted: 07/01/2011] [Indexed: 10/17/2022]
Abstract
INTRODUCTION The indications for adrenalectomy could be changing by the availability of laparoscopy and the growing detection of incidentalomas. The Endocrine Surgery Section of the Spanish Association of Surgeons conducted a survey to analyse the current indications for adrenalectomy and their results in Spanish surgical departments. MATERIAL AND METHODS Data was gathered as regards the type of hospital and department, volume of procedures, localisation studies and pre-surgical preparations, indications, surgical approach, and results in terms of morbidity and hospital stay. The results of the centres were compared as regards their volume of activity using the Mann-Whitney Test for the quantitative variables and chi squared for the qualitative ones. RESULTS Thirty-six centres completed the questionnaire and 301 adrenalectomies were reported to be performed in 2008. Most frequent indications were pheochromocytoma (25.2%), non-functioning adenoma (16.2%), aldosteronoma (15.9%), Cushing adenoma (11.2%), metastasis (10.3%), myelolipoma (5.6%), and carcinoma (4.9%). Laparoscopic adrenalectomy was performed in 83.7% of cases (6.7% required conversion to laparotomy). The mean hospital stay was 3.9 days for laparoscopic adrenalectomy and 7.4 days for laparotomy. High-volume units (more than 10 per year) used more frequently the laparoscopic approach (P=.019), and had a shorter overall hospital stay (P<.0001). Laparoscopic adrenalectomy was also associated with a shorter hospital stay (P<.0001). CONCLUSIONS Laparoscopy for adrenalectomy has become the standard practice in Spain, with good results in terms of morbidity and hospital stay. High volume centres have better results as regards the use of minimally invasive surgery and hospital stay.
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