Pancreaticoduodenectomy: A study from India on the impact of evolution from a low to a high volume unit

Table 1 Histopathological type

Variable	n (%)
Pancreatic adenocarcinoma	85 (42.5)
Ampullary adenocarcinoma	57 (28.5)
Distal cholangiocarcinoma	23 (11.5)
Duodenal adenocarcinoma	10 (5.0)
Neuroendocrine tumors	7 (3.5)
Serous cystadenoma	3 (1.5)
Chronic pancreatitis	3 (1.5)
Mucinous cystadenoma	2 (1.0)
Intra-ductal papillary mucinous neoplasm	2 (1.0)
Pancreatoblastoma	2 (1.0)
Gastrointestinal stromal tumors	2 (1.0)
Pancreatic sarcoma	1 (0.5)
Duodenal leiomyoma	1 (0.5)
Angiomyolipoma	1 (0.5)
Mucinous cystoadenocarcinoma	1 (0.5)

Table 2 Demographic characterization

Variable	Low volume (< 10 PDs/yr), n = 20	Medium volume (10-24 PDs/yr), n = 44	High volume (≥ 25 PDs/yr), n = 136	P value
Gender (male/female)	12/8	25/19	80/56	0.963
Age (yr), mean ± SD	58.95 ± 10.44	59.22 ± 10.29	62.58 ± 9.05	0.059
BMI, mean ± SD	21.00 ± 2.55	21.59 ± 2.76	21.45 ± 2.50	0.691
ASA score, n (%)
1	3 (15.0)	6 (13.6)	16 (11.8)
2	12 (60.0)	26 (59.2)	78 (57.4)
3	4 (20.0)	10 (22.7)	34 (25.0)	0.996
4	1 (50.0)	2 (4.5)	8 (5.8)
Jaundice, n (%)	16 (80.0)	32 (72.7)	105 (77.2)	0.770
Abdominal pain, n (%)	7 (35.0)	15 (34.1)	40 (29.4)	0.776
Vomiting, n (%)	4 (20.0)	7 (15.9)	24 (17.6)	0.920
Cholangitis, n (%)	3 (15.0)	6 (13.6)	26 (19.1)	0.674
Diabetes, n (%)	3 (15.0)	9 (20.5)	23 (16.9)	0.825
CV disease, n (%)	3 (15.0)	7 (15.9)	18 (13.2)	0.898
Cold, n (%)	2 (10.0)	4 (9.1)	8 (5.9)	0.659
Preoperative Hb (mg/dL), mean ± SD	9.37 ± 1.19	9.73 ± 1.44	9.62 ± 1.19	0.558
Preoperative albumin (mg/dL)	3.33 ± 0.52	3.52 ± 0.58	3.56 ± 2.68	0.914
Serum bilirubin (mg/dL), mean ± SD	9.48 ± 5.38	8.56 ± 4.00	9.11 ± 5.38	0.754
Preoperative biliary stenting, n (%)	3 (15.0)	8 (18.2)	19 (14.0)	0.794

Table 3 Comparative analyses of features in the perioperative period during the progress from a low to a high volume PD centre, n (%)

Variable	Low volume (< 10 PDs/yr), n = 20	Medium volume (10-24 PDs/yr), n = 44	High volume (≥ 25 PDs/yr), n = 136
Preoperative
Triple phase CECT abdomen/pelvis	10 (50)	40 (90.9)	136 (100)
CA 19.9	10 (50)	44 (100)	136 (100)
Operative
Classical Whipple	14 (70)	12 (27.3)	4 (2.9)
PPPD	6 (30)	32 (72.7)	132 (97.1)
With portal vein resection	0 (0)	0 (0)	4 (2.9)
With right hemicolectomy	0 (0)	2 (4.5)	6 (4.4)
Pancreaticojejunostomy
Duct to mucosa	17 (85)	5 (11.4)	0 (0)
Dunking	3 (15)	39 (88.6)	136 (100)
Use of pyloric dilatation	0 (0)	32 (72.7)	132 (97.1)
Use of omental flap[8]	0 (0)	10 (22.7)	136 (100)
No of abdominal drains
1 drain	4 (20)	39 (88.6)	136 (100)
2 drains	16 (80)	5 (11.4)	0 (0)
Feeding jejunostomy	15 (75)	26 (59.1)	10 (7.4)
Octreotide 0.1 mg S/C × 3 times for 1 wk	15 (75)	10 (22.7)	0 (0)
Postoperative
Fast track approach[10]	0 (0)	16 (36.4)	126 (92.6)

CA 19.9: Carbohydrate antigen 19.9; PPPD: Pylorus preserving pancreaticoduodenectomy.

Table 4 Operative details

Variable	Low volume (< 10 PDs/yr), n = 20	Medium volume (10-24 PDs/yr), n = 44	High volume (≥ 25 PDs/yr), n = 136	P value
Duration of surgery in minutes, mean ± SD	246.3 ± 20.6	227.7 ± 47.5	125.5 ± 16.1	< 0.001
Operative blood loss in millilitre, mean ± SD	1098.5 ± 163.8	932.3 ± 207.5	415.9 ± 82.7	< 0.001
Intraoperative blood transfusion required, no of patients (%)	20 (100)	41 (93.2)	23 (16.9)	< 0.001
Mean blood units transfused, mean ± SD	1.3 ± 0.4	1.3 ± 0.6	0.2 ± 0.4 (0-1)	< 0.001
Pancreatic texture, n (%)
Soft	4 (20.0)	11 (25.0)	30 (22.1)
Intermediate	11 (55.0)	20 (45.5)	72 (52.9)	0.925
Firm	5 (25.0)	13 (29.5)	34 (25.0)
Pancreatic duct diameter at neck, n (%)
< 3 mm	7 (35.0)	12 (27.3)	46 (33.8)	0.700
≥ 3 mm	13 (65.0)	32 (72.7)	90 (66.2)
Feeding jejunostomy, n (%)	15 (75.0)	26 (59.1)	10 (7.4)	< 0.001

PD: Pancreaticoduodenectomy.

Table 5 Postoperative complications and outcome

Variable	Low volume (< 10 PDs/yr), n = 20	Medium volume (10-24 PDs/yr), n = 44	High volume (≥ 25 PDs/yr), n = 136	P value
Pancreatic fistula, n (%)	3 (15.0)	7 (15.9)	5 (3.6)
Grade A	1 (33.3)	3 (42.8)	2 (40.0)	0.011
Grade B	1 (33.3)	3 (42.8)	2 (40.0)
Grade C	1 (33.3)	1 (14.3)	1 (20.0)
Delayed gastric emptying, n (%)	4 (20.0)	8 (18.2)	8 (5.9)
Grade A	2	6	7
Grade B	1	2	1	0.018
Grade C	1	0	0
Hemorrhage, n (%)	2	1	0
Grade A	1	0	0	0.007
Grade B	0	1	0
Grade C	1	0	0
Intra-abdominal infection, n (%)	1 (5.0)	2 (4.5)	1 (0.7)	0.175
Bile leak, n (%)	1 (5.0)	2 (4.5)	2 (1.5)	0.395
Total morbidity, n (%)	10 (50.0)	20 (45.5)	37 (27.2)	0.021
Major morbidity (Clavien grade III, IV)	3 (15.0)	2 (4.5)	3 (2.2)	0.024
Reoperation, n (%)	2 (10.0)	2 (4.5)	1 (0.7)	0.029
Mortality, n (%)	2 (10)	1 (2.2)	0	0.007
Postoperative length of hospital stay (d), mean ± SD	11.8 ± 3.4	11.3 ± 2.9	7.9 ± 1.7	< 0.001

PD: Pancreaticoduodenectomy.