• Complication
• Failure
• Morbidity
• Mortality
• Pancreas
• Pancreaticoduodenectomy
• Rescue

• Outcomes
• Pancreas
• Resection
• Volume
• Whipples

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.

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.

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.

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.

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.

• Pancreas
• Surgery
• Pancreatectomy
• Whipple’s
• Pancreaticoduodenectomy

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.

• Pancreas
• Surgery
• Pancreatectomy
• Whipple’s
• Pancreaticoduodenectomy

• Accreditation
• Centralisation
• Complex cancer
• External quality assessment
• Government regulation
• High-volume centres
• Minimum volumes
• Pancreatic cancer
• Pancreatic surgery

• Delivery of Health Care
• Digestive System Surgical Procedures
• Hospitals
• Humans
• Pancreatic Neoplasms/surgery

• Adult
• Aged
• Aged, 80 and over
• Female
• Hospitals/standards
• Hospitals/statistics & numerical data
• Humans
• Length of Stay/statistics & numerical data
• Lymph Node Excision/adverse effects
• Lymph Node Excision/statistics & numerical data
• Male
• Margins of Excision
• Middle Aged
• Multivariate Analysis
• Pancreatic Neoplasms/surgery
• Pancreaticoduodenectomy/adverse effects
• Pancreaticoduodenectomy/standards
• Pancreaticoduodenectomy/statistics & numerical data
• Postoperative Complications/epidemiology
• Postoperative Complications/etiology
• Quality of Health Care/standards
• Quality of Health Care/statistics & numerical data
• Risk Factors
• Spain/epidemiology
• Young Adult

General surgical operations on patients with cirrhosis have historically been associated with high morbidity and mortality rates. This study examines a contemporary series of patients with cirrhosis undergoing general surgical procedures.

A retrospective evaluation of 358 cirrhotic patients undergoing general surgical operations at a single institution between 2004–2015 was performed. Thirty- and 90-day mortality along with complications and subsequent transplantation rates were examined.

358 cirrhotic patients were identified. The majority were Child-Turcotte-Pugh class (CTP) A (55.9%) followed by class B (32.4%) and class C (11.7%). Mean MELD score differed significantly between the groups (8.7 vs. 12.1 vs. 20.1; p<0.001). The most common operations were herniorrhaphy (29.9%), cholecystectomy (19.3%), and liver resection (14.5%). The majority of cases were performed semi-electively (68.4%), however, within the CTP C patients most cases were performed emergently (73.8%). Thirty and 90-day mortality for all patients were 5% and 6%, respectively. Mortality rates increased from CTP A to CTP C (30 day: 3.0% vs. 5.2% vs. 14.3%; p = 0.01; 90 day: 4.5% vs. 6.9% vs. 16.7%; p = 0.016). Additionally, 30-day mortality (12.8% vs. 2.3%; p<0.001), 90 day mortality (16.0% vs. 3.4%; p<0.001) were higher for emergent compared to elective cases. A total of 13 (3.6%) patients underwent transplantation ≤ 90 days from surgery. No elective cases resulted in an urgent transplantation.

Performing general surgical operations on cirrhotic patients carries a significant morbidity and mortality. This contemporary series from a specialized liver center demonstrates improved outcomes compared to historical series. These data strongly support early referral of cirrhotic patients needing general surgical operation to centers with liver expertise to minimize morbidity and mortality.

• Adult
• Aged
• Aged, 80 and over
• Elective Surgical Procedures
• Female
• Humans
• Liver Cirrhosis/epidemiology
• Liver Cirrhosis/pathology
• Liver Cirrhosis/surgery
• Male
• Middle Aged
• Mortality
• Odds Ratio
• Outcome Assessment, Health Care
• Patient Care/methods
• Patient Care/standards
• Quality Improvement
• Severity of Illness Index
• Young Adult

• hepatopancreaticobiliary surgery
• outcome
• pancreaticoduodenectomy
• volume

Pancreatic cancer surgery is increasingly regionalized in high‐volume centres. Provision of adjuvant chemotherapy in the same institution can place a burden on patients, whereas receiving adjuvant chemotherapy at a different institution closer to home may create disparities in care. This study compared long‐term outcomes of patients with pancreatic adenocarcinoma receiving adjuvant chemotherapy at the institution where they had undergone surgery with outcomes for those receiving chemotherapy at a different institution.

This was a population‐based study of patients receiving adjuvant chemotherapy after resection of pancreatic adenocarcinoma performed at ten designated hepatopancreatobiliary centres in Ontario, Canada, between 2004 and 2014. Patients were divided into those receiving chemotherapy at the same institution as surgery or a different institution from where surgery was performed. The primary outcome was overall survival (OS). Multivariable Cox regression assessed the association between OS and each chemotherapy group, adjusted for potential confounders.

Of 589 patients, 374 (63·5 per cent) received adjuvant chemotherapy at the same institution as surgery. After adjusting for age, sex, co‐morbidity, socioeconomic status, rural living, tumour stage, margin positivity and year of surgery, the location of adjuvant chemotherapy was not independently associated with OS (hazard ratio 1·03, 95 per cent c.i. 0·85 to 1·24). For patients who underwent chemotherapy at a different institution, mean travel distance to receive chemotherapy was less (22·9 km) than that needed for surgery (106·7 km).

After pancreatectomy for pancreatic adenocarcinoma at specialized hepatopancreatobiliary surgery centres, OS was not affected by the location of the centre delivering adjuvant chemotherapy. Receiving this treatment in a local centre reduced patients' travel burden.

• Aged
• Calibration
• Female
• Hospital Mortality
• Humans
• Male
• Pancreatectomy/mortality
• Pancreatic Neoplasms/mortality
• Pancreatic Neoplasms/surgery
• Probability
• Regression Analysis

• (SRTR)
• Scientific Registry for Transplant Recipients
• clinical research/practice
• graft survival
• health services and outcomes research
• infection and infectious agents
• infectious disease
• kidney (allograft) function/dysfunction
• kidney transplantation/nephrology
• patient survival
• viral: human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS)

• Acute Kidney Injury/pathology
• Adolescent
• Adult
• Biopsy/adverse effects
• Female
• Hematuria/pathology
• Hospital Mortality
• Hospitals, High-Volume/statistics & numerical data
• Hospitals, Low-Volume/statistics & numerical data
• Humans
• Incidence
• Japan/epidemiology
• Kidney/pathology
• Kidney Diseases/pathology
• Male
• Middle Aged
• Nephrotic Syndrome/pathology
• Postoperative Hemorrhage/epidemiology
• Postoperative Hemorrhage/etiology
• Postoperative Hemorrhage/therapy
• Renal Insufficiency, Chronic/pathology
• Risk Factors
• Young Adult