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Maharjan U, Kauppila JH. University hospital status and gastric cancer mortality: A population-based nationwide study in Finland. J Gastrointest Surg 2025; 29:101932. [PMID: 39701514 DOI: 10.1016/j.gassur.2024.101932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2024] [Revised: 11/23/2024] [Accepted: 12/14/2024] [Indexed: 12/21/2024]
Abstract
BACKGROUND Gastric cancer remains a significant global health issue with increasing mortality, despite advancements in treatment. Previous studies have suggested that surgery performed at university hospitals may influence surgical outcomes and mortality rates, but evidence of its effect on gastric cancer remains limited. This study aimed to investigate whether gastrectomy performed at university hospitals reduces short-term and long-term mortality rates in Finland. METHODS This nationwide population-based retrospective cohort study analyzed patients with gastric cancer who underwent gastrectomy in Finland from 1987 to 2016, using data from the Finnish Cancer Registry, Finnish Patient Registry, and Finnish Death Registry. The study compared 5-year, 30-day, and 90-day all-cause mortality rates between patients treated at university hospitals and those treated at nonuniversity hospitals, with adjustments for confounders using multivariate Cox regression models. RESULTS Of 10,455 patients who underwent gastrectomy in Finland between 1987 and 2016, most were treated in nonuniversity hospitals. Patients who underwent gastrectomy at university hospitals were generally younger and had more comorbidities and more advanced cancer stages. Of note, 30-day, 90-day, and 5-year survival rates were higher in university hospitals than in nonuniversity hospitals, although the differences in 90-day and 5-year survival rates were not statistically significant in more recent years. CONCLUSION Our findings suggest that gastrectomy performed at university hospitals in Finland is associated with lower short-term and long-term mortality rates than gastrectomy performed at nonuniversity hospitals. In addition, our findings support the potential benefits of centralizing gastric cancer surgical procedures at university hospitals. However, further research is needed to explore the underlying reasons.
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Affiliation(s)
- Urgena Maharjan
- Surgery Research Unit, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland.
| | - Joonas H Kauppila
- Surgery Research Unit, Medical Research Center Oulu, Oulu University Hospital, University of Oulu, Oulu, Finland; Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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Thomas AS, Tehranifar P, Kwon W, Shridhar N, Sugahara KN, Schrope BA, Chabot JA, Manji GA, Genkinger JM, Kluger MD. Trends in the Care of Locally Advanced Pancreatic Cancer in the Modern Era of Chemotherapy. J Surg Oncol 2024; 130:1589-1604. [PMID: 39348434 DOI: 10.1002/jso.27851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 08/04/2024] [Accepted: 08/18/2024] [Indexed: 10/02/2024]
Abstract
INTRODUCTION Current guidelines for treatment for locally advanced pancreatic cancer recommend chemotherapy ± radiation, or radiation alone when multimodal therapy is contraindicated. In a subset of patients, guideline-recommended treatment (GRT) achieves sufficient response to qualify for potentially curative resection. This study evaluated trends in treatment utilization and aimed to identify barriers to GRT. METHODS Patients with clinical T4M0 disease in the National Cancer Database from 2010 to 2017 were included. Potential predictors were assessed by relative risk regression with Poisson distribution and compared by log-link function. RESULTS In total, 28 056 patients met the criteria. Among 17 059 (67.67%) patients treated primarily with chemotherapy, 41.19% also had radiation and 8.89% went onto resection. Many received no cancer-directed treatment or failed to receive GRT. Another 710 patients had radiation (±surgery) without chemotherapy despite few contraindications to chemotherapy. Over time, patients were more likely to undergo resection after chemotherapy (aRR = 1.58; p < 0.0001) and less likely to have chemoradiation (aRR = 0.78; p < 0.0001) or go untreated (aRR = 0.90; p < 0.0001). Socioeconomic factors (race, education, income, and insurance status) affected the likelihood of receiving chemotherapy and surgery. Median overall survival (OS) was significantly improved for patients treated with chemotherapy and particularly in those patients who went on to receive RT or undergo surgical resection. OS was also longer for patients treated at high-volume academic centers. Patients insured by Medicaid, Medicare, or those without insurance had worse OS. CONCLUSIONS Despite improvement over time, many patients go untreated. Clinical factors were influential, but the impact of vulnerable social standing suggests persistent inequity in access to care.
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Affiliation(s)
- Alexander S Thomas
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Parisa Tehranifar
- Herbert Irving Comprehensive Cancer Center Cancer Population Science Program, New York, New York, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Wooil Kwon
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University Irving Medical Center, New York, New York, USA
- Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - Nupur Shridhar
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Kazuki N Sugahara
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Beth A Schrope
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - John A Chabot
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Gulam A Manji
- Division of Hematology and Oncology, Columbia University Irving Medical Center, New York, New York, USA
- Herbert Irving Comprehensive Cancer Center, New York, New York, USA
| | - Jeanine M Genkinger
- Herbert Irving Comprehensive Cancer Center Cancer Population Science Program, New York, New York, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Michael D Kluger
- Department of Surgery, Division of Gastrointestinal and Endocrine Surgery, Columbia University Irving Medical Center, New York, New York, USA
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Jaquet R, Challine A, Tzedakis S, de Ponthaud C, Katsahian S, Lefevre J, Lazzati A. Impact of the thresholds of surgical volume on mortality in oncological digestive surgery: A French National Cohort. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108581. [PMID: 39151307 DOI: 10.1016/j.ejso.2024.108581] [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: 07/04/2024] [Accepted: 08/02/2024] [Indexed: 08/19/2024]
Abstract
OBJECTIVE To report the 90-day mortality benefit associated with the implementation of the new regulatory reform on oncological surgical digestive authorizations. SUMMARY BACKGROUND DATA New thresholds in digestive cancer surgery were applied in 2023, accrediting centers for major interventions. No evidence has been provided to support their justification. METHODS Any French adult operated for digestive cancer from January 1, 2019 to December 31, 2021 was included from the PMSI. A 90-day mortality logistic regression was performed by adjusting by age, sex, Charlson score, Frailty index, hospital-volume (<5 or ≥5 interventions/year), emergency intervention, specialty. RESULTS 143,582 patients were identified. Of these, 64,268 underwent surgery of one of the subspecialties subject to the new thresholds (stomach N = 8283, liver N = 18,668, pancreas N = 11,220, esophagus N = 3704, rectum N = 22,393). 4808 (7.5 %) patients underwent surgery in low-volume centers, distributed as follows: stomach 1757/8283 (22.94 %), liver 970/18,668 (5.19 %), pancreas 895/11,220 (7.98 %), esophagus 672/3704 (18.14 %) and rectum 514/22,393 (2.29 %). In univariate analysis, the 90-day mortality rate was significantly lower in high-volume centers, for all subspecialties, gastric: 127/1757 (7.23 %) vs 330/6526 (5.06 %), p = 0.0004, hepatic: 64/970 (6.6 %) vs 824/17,698 (4.66 %), p = 0.006, pancreatic: 74/895 (8, 27 %) vs 608/10,325 (5.89 %), p = 0.004, esophageal: 58/672 (8.63 %) vs 195/3032 (6.43 %), p = 0.04, rectal 26/514 (5.06 %) vs 639/21,879 (2.92 %), p = 0.005. The multivariate analysis, showed a mortality reduction for high-volume centers: OR = 0.78 CI95[0.71-0.87], p < 0.001. CONCLUSION The recent implementation of regulatory decrees appears to be justified. The enforcement of these hospital volume thresholds is likely to contribute to a reduction in postoperative mortality following digestive cancer surgery.
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Affiliation(s)
- Romain Jaquet
- Visceral Surgery Department, 159 Rue Du Président François Mitterrand, 91160, Longjumeau, France; North Essonne Hospital Group, Longjumeau Site, France; UMRS Unit 1138 Heka/Inria Team Cordeliers Research Center, 15 Rue de l'École de Médecine, 75006, Paris, France.
| | - Alexandre Challine
- UMRS Unit 1138 Heka/Inria Team Cordeliers Research Center, 15 Rue de l'École de Médecine, 75006, Paris, France; General and Digestive Surgery Department, Saint-Antoine Hospital, 184 Rue Du Faubourg Saint-Antoine, 75012, Paris, France
| | - Stylianos Tzedakis
- UMRS Unit 1138 Heka/Inria Team Cordeliers Research Center, 15 Rue de l'École de Médecine, 75006, Paris, France; Hepato-biliary-endocrine Digestive Surgery Department - Cochin Hospital - 27 Rue Du Faubourg Saint-Jacques, 75014, Paris, France
| | - Charles de Ponthaud
- UMRS Unit 1138 Heka/Inria Team Cordeliers Research Center, 15 Rue de l'École de Médecine, 75006, Paris, France; Department of Hepatoboiliary, Pancreatic, Endocrine and Transplantation - La Pitié Salpêtrière Hospital, AP-HP, 47-83 Bd de l'Hôpital, 75013, Paris, France
| | - Sandrine Katsahian
- UMRS Unit 1138 Heka/Inria Team Cordeliers Research Center, 15 Rue de l'École de Médecine, 75006, Paris, France
| | - Jérémie Lefevre
- General and Digestive Surgery Department, Saint-Antoine Hospital, 184 Rue Du Faubourg Saint-Antoine, 75012, Paris, France
| | - Andrea Lazzati
- UMRS Unit 1138 Heka/Inria Team Cordeliers Research Center, 15 Rue de l'École de Médecine, 75006, Paris, France; General Digestive and Obesity Surgery Department - Avicenne Hospital, 125 Rue de Stalingrad 93000 Bobigny, France
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Seufferlein T, Mayerle J, Boeck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie Exokrines Pankreaskarzinom – Version 3.1. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:1724-1785. [PMID: 39389105 DOI: 10.1055/a-2338-3716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/12/2024]
Affiliation(s)
| | | | | | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Gastroenterologie und Endokrinologie Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik und Poliklinik für Allgemein-, Viszeral- und Thoraxchirurgie, Universitätsklinikum Hamburg-Eppendorf, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Medizinische Klinik und Poliklinik II Onkologie und Hämatologie, Universitätsklinikum Hamburg-Eppendorf, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
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Seufferlein T, Mayerle J, Boeck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie Exokrines Pankreaskarzinom – Version 3.1. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:e874-e995. [PMID: 39389103 DOI: 10.1055/a-2338-3533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/12/2024]
Affiliation(s)
| | | | | | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Gastroenterologie und Endokrinologie Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik und Poliklinik für Allgemein-, Viszeral- und Thoraxchirurgie, Universitätsklinikum Hamburg-Eppendorf, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Medizinische Klinik und Poliklinik II Onkologie und Hämatologie, Universitätsklinikum Hamburg-Eppendorf, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
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Pourali G, Donyadideh G, Mehrabadi S, Hamid F, Hassanian SM, Ferns GA, Khazaei M, Avan A. Clinical practice guidelines for interventional treatment of pancreatic cancer. RECENT ADVANCES IN NANOCARRIERS FOR PANCREATIC CANCER THERAPY 2024:345-373. [DOI: 10.1016/b978-0-443-19142-8.00008-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2025]
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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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Seufferlein T, Mayerle J, Böck S, Brunner T, Ettrich TJ, Grenacher L, Gress TM, Hackert T, Heinemann V, Kestler A, Sinn M, Tannapfel A, Wedding U, Uhl W. S3-Leitlinie zum exokrinen Pankreaskarzinom – Langversion 2.0 – Dezember 2021 – AWMF-Registernummer: 032/010OL. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:e812-e909. [PMID: 36368658 DOI: 10.1055/a-1856-7346] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
| | | | - Stefan Böck
- Medizinische Klinik und Poliklinik III, Universitätsklinikum München, Germany
| | - Thomas Brunner
- Universitätsklinik für Strahlentherapie-Radioonkologie, Medizinische Universität Graz, Austria
| | | | | | - Thomas Mathias Gress
- Klinik für Gastroenterologie und Endokrinologie, Universitätsklinikum Gießen und Marburg, Germany
| | - Thilo Hackert
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie Universitätsklinikum, Heidelberg, Germany
| | - Volker Heinemann
- Medizinische Klinik und Poliklinik III, Klinikum der Universität München-Campus Grosshadern, München, Germany
| | | | - Marianne Sinn
- Universitätsklinikum Hamburg-Eppendorf Medizinische Klinik und Poliklinik II Onkologie Hämatologie, Hamburg, Germany
| | | | | | - Waldemar Uhl
- Allgemein- und Viszeralchirurgie, St Josef-Hospital, Bochum, Germany
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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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Ratnayake B, Pendharkar SA, Connor S, Koea J, Sarfati D, Dennett E, Pandanaboyana S, Windsor JA. Patient volume and clinical outcome after pancreatic cancer resection: A contemporary systematic review and meta-analysis. Surgery 2022; 172:273-283. [PMID: 35034796 DOI: 10.1016/j.surg.2021.11.029] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 11/02/2021] [Accepted: 11/29/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Pancreatic cancer remains a highly fatal disease with a 5-year overall survival of less than 10%. In seeking to improve clinical outcomes, there is ongoing debate about the weight that should be given to patient volume in centralization models. The aim of this systematic review is to examine the relationship between patient volume and clinical outcome after pancreatic resection for cancer in the contemporary literature. METHODS The Google Scholar, PubMed, and Cochrane Library databases were systematically searched from February 2015 until June 2021 for articles reporting patient volume and outcomes after pancreatic cancer resection. RESULTS There were 46 eligible studies over a 6-year period comprising 526,344 patients. The median defined annual patient volume thresholds varied: low-volume 0 (range 0-9), medium-volume 9 (range 3-29), high-volume 19 (range 9-97), and very-high-volume 28 (range 17-60) patients. The latter 2 were associated with a significantly lower 30-day mortality (P < .001), 90-day mortality (P < .001), overall postoperative morbidity (P = .005), failure to rescue rate (P = .006), and R0 resection rate (P = .008) compared with very-low/low-volume hospitals. Centralization was associated with lower 30-day mortality in 3 out of 5 studies, while postoperative morbidity was similar in 4 out of 4 studies. Median survival was longer in patients traveling greater distance for pancreatic resection in 2 out of 3 studies. Median and 5-year survival did not differ between urban and rural settings. CONCLUSION The contemporary literature confirms a strong relationship between patient volume and clinical outcome for pancreatic cancer resection despite expected bias toward more complex surgery in high-volume centers. These outcomes include lower mortality, morbidity, failure-to-rescue, and positive resection margin rates.
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Affiliation(s)
- Bathiya Ratnayake
- Surgical and Translational Research Centre, Faculty of Medical and Health Science, University of Auckland, New Zealand; HBP/Upper GI Unit, Auckland City Hospital, Auckland, New Zealand. https://twitter.com/ProfJohnWindsor
| | - Sayali A Pendharkar
- Surgical and Translational Research Centre, Faculty of Medical and Health Science, University of Auckland, New Zealand
| | - Saxon Connor
- Department of Surgery, Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Jonathan Koea
- Upper GI Unit, Northshore Hospital, Waitemata District Health Board, Auckland, New Zealand
| | - Diana Sarfati
- Department of Public Health, University of Otago, Dunedin, New Zealand; Cancer Control Agency, Te Aho O Te Kahu, Ministry of Health, New Zealand
| | - Elizabeth Dennett
- Cancer Control Agency, Te Aho O Te Kahu, Ministry of Health, New Zealand
| | - Sanjay Pandanaboyana
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle upon Tyne, Tyne and Wear, UK; Population Health Sciences Institute, Newcastle University, Newcastle, UK
| | - John A Windsor
- Surgical and Translational Research Centre, Faculty of Medical and Health Science, University of Auckland, New Zealand; HBP/Upper GI Unit, Auckland City Hospital, Auckland, New Zealand.
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Huhta H, Nortunen M, Meriläinen S, Helminen O, Kauppila JH. Hospital volume and outcomes of pancreatic cancer: a Finnish population-based nationwide study. HPB (Oxford) 2022; 24:841-847. [PMID: 34824013 DOI: 10.1016/j.hpb.2021.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 10/13/2021] [Accepted: 10/22/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pancreatic cancer surgery is associated with high incidence of short- and long-term morbidity and mortality. The aim of this study was to assess whether the hospital volume of pancreatic surgery is associated with better survival in a population-based setting. METHODS All patients who underwent pancreatic resection for cancer in Finland during 1997-2016 were identified from nationwide registries. The follow-up ended on 31 December 2019. Patients were divided into quintiles based on annual hospital volume (4-year moving average): ≤4, 5-9, 10-18, 19-36 and ≥ 37 resections per year. Cox regression provided hazard ratios (HR) and 95% confidence intervals (CI), adjusted for age, sex, comorbidity and year of surgery. RESULTS The number of diagnosed pancreatic cancers was 22,724. Of these, 1514 underwent pancreatic surgery due to pancreatic ductal adenocarcinoma. The 5-year survival ranged from 12% to 28%, increasing with higher annual operative volume. Adjusted 5-year mortality was higher in all other quintiles compared to the highest annual volume quintile (HR 1.43, 95% CI 1.16-1.75). Thirty and 90-day mortality were higher in the three lowest volume, compared to the highest quintile. CONCLUSION Higher annual hospital volume of pancreatic surgery for pancreatic ductal adenocarcinoma is associated with improved short- and long-term survival.
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Affiliation(s)
- Heikki Huhta
- Surgery and Intensive Care Research Unit, Oulu University Hospital, Oulu, Finland.
| | - Minna Nortunen
- Surgery and Intensive Care Research Unit, Oulu University Hospital, Oulu, Finland
| | - Sanna Meriläinen
- Surgery and Intensive Care Research Unit, Oulu University Hospital, Oulu, Finland
| | - Olli Helminen
- Surgery and Intensive Care Research Unit, Oulu University Hospital, Oulu, Finland
| | - Joonas H Kauppila
- Surgery and Intensive Care Research Unit, Oulu University Hospital, Oulu, Finland; Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden
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13
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Hunger R, Seliger B, Ogino S, Mantke R. Mortality factors in pancreatic surgery: A systematic review. How important is the hospital volume? Int J Surg 2022; 101:106640. [PMID: 35525416 PMCID: PMC9239346 DOI: 10.1016/j.ijsu.2022.106640] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 04/18/2022] [Accepted: 04/21/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND How the extent of confounding adjustment impact (hospital) volume-outcome relationships in published studies on pancreatic cancer surgery is unknown. METHODS A systematic literature search was conducted for studies that investigated the relationship between volume and outcome using a risk adjustment procedure by querying the following databases: PubMed, Cochrane Central Register of Controlled Trials, Livivo, Medline and the International Clinical Trials Registry Platform (last query: 2020/09/16). Importance of risk-adjusting covariates were assessed by effect size (odds ratio, OR) and statistical significance. The impact of covariate adjustment on hospital (or surgeon) volume effects was analyzed by regression and meta-regression models. RESULTS We identified 87 studies (75 based on administrative data) with nearly 1 million patients undergoing pancreatic surgery that included in total 71 covariates for risk adjustment. Of these, 33 (47%) had statistically significant effects on short-term mortality and 23 (32%) did not, while for 15 (21%) factors neither effect size nor statistical significance were reported. The most important covariates for short term mortality were patient-specific factors. Concerning the covariates, single comorbidities (OR: 4.6, 95% CI: 3.3 to 6.3) had the strongest impact on mortality followed by hospital volume (OR: 2.9, 95% CI: 2.5 to 3.3) and the procedure (OR: 2.2, 95% CI: 1.9 to 2.5). Among the single comorbidities, coagulopathy (OR: 4.5, 95% CI: 2.8 to 7.2) and dementia (OR: 4.2, 95% CI: 2.2 to 8.0) had the strongest influence on mortality. The regression analysis showed a significant decrease hospital volume effect with an increasing number of covariates considered (OR: 0.06, 95% CI: 0.10 to -0.03, P < 0.001), while such a relationship was not observed for surgeon volume (P = 0.35). CONCLUSIONS This analysis demonstrated a significant inverse relationship between the extent of risk adjustment and the volume effect, suggesting the presence of unmeasured confounding and overestimation of volume effects. However, the conclusions are limited in that only the number of included covariates was considered, but not the effect size of the non-included covariates.
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Affiliation(s)
- Richard Hunger
- Faculty of Medicine, University Hospital Brandenburg, Brandenburg Medical School Theodor Fontane, Brandenburg, Germany
| | - Barbara Seliger
- Martin Luther University Halle-Wittenberg, Institute of Medical Immunology, Halle, Germany; Fraunhofer Institute for Cell Therapy and Immunology, Leipzig, Germany
| | - Shuji Ogino
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA; Program in MPE Molecular Pathological Epidemiology, Department of Pathology, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA; Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Rene Mantke
- Faculty of Medicine, University Hospital Brandenburg, Brandenburg Medical School Theodor Fontane, Brandenburg, Germany; Faculty of Health Sciences, Brandenburg Medical School Theodor Fontane, Brandenburg, Germany.
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14
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Lee S, Maegawa FB, Joseph S, Alvarado LA, Mendoza-Ladd A, Elhanafi S, Philipovskiy A, Tyroch AH, Konstantinidis IT. Pancreatic Neuroendocrine Tumors: The Effect of Facility Type on Patient Survival. Pancreas 2022; 51:282-287. [PMID: 35584387 DOI: 10.1097/mpa.0000000000002014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES During the last decades, significant progress has been made in the management of patients with pancreatic neuroendocrine tumors (pNETs). It is unclear how the type of the treating health care facility alters patient outcomes. METHODS Data from pNETs reported to the National Cancer Database between 2004 and 2016 were examined. Types of institutions were as follows: academic/research cancer program (ARP), comprehensive community cancer program (CCCP), integrated network cancer program (INCP), and community cancer program (CCP). RESULTS A total of 17,887 patients with pNETs were analyzed. Treatment at ARPs was significantly associated with receipt of surgery (ARP, 61.9%; CCCP, 45.6%; CCP, 29.9%; INCP, 55.5%; P < 0.001), both for patients with very early tumors ≤2 cm (ARP, 74.7%; CCCP, 66.5%; CCP, 52.4%; INCP, 71.6%; P < 0.001) and for patients with liver metastases (ARP, 21.3%; CCCP, 10.6%; CCP, 5%; INCP, 16.8%; P < 0.001). Treatment at ARPs was associated with improved survival (median overall survival: ARP, 91 mo; CCCP, 47 mo; CCP, 24.5 mo; INCP, 72 mo; P < 0.001). CONCLUSIONS Treatment of pNETs at academic/research programs is associated with more frequent resections and best survival outcomes. This survival benefit exists for early and late stages and after adjusting for known cofactors.
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Affiliation(s)
- Sara Lee
- From the Department of Surgery, Texas Tech University Health Sciences Center, El Paso, TX
| | | | - Sharon Joseph
- From the Department of Surgery, Texas Tech University Health Sciences Center, El Paso, TX
| | | | | | | | | | - Alan H Tyroch
- From the Department of Surgery, Texas Tech University Health Sciences Center, El Paso, TX
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15
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Wirth K, Näpflin M, Graber SM, Blozik E. Does hospital volume affect outcomes after abdominal cancer surgery: an analysis of Swiss health insurance claims data. BMC Health Serv Res 2022; 22:262. [PMID: 35219332 PMCID: PMC8881861 DOI: 10.1186/s12913-022-07513-5] [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: 07/13/2021] [Accepted: 01/13/2022] [Indexed: 11/10/2022] Open
Abstract
Background Medical treatment quality has been shown to be better in high volume than in low volume hospitals. However, this relationship has not yet been confirmed in abdominal cancer in Switzerland and is relevant for referral of patients and healthcare planning. Thus, the present study investigates the association between hospital volumes for surgical resections of colon, gastric, rectal, and pancreatic carcinomas and outcomes. Methods This retrospective analysis is based on anonymized claims data of patients with mandatory health insurance at Helsana Group, a leading health insurance in Switzerland. Outcome parameters were length of hospital stay, mortality and cost during the inpatient stay as well as at 1-year follow-up. Hospital volume information was derived from the Quality Indicators dataset provided by the Swiss Federal Office of Public Health. The impact of hospital volume on the different treatment outcomes was statistically tested using generalized estimating equations (GEE) models, taking into account the non-independence of observations from the same hospital. Results The studies included 2′859 resections in patients aged 18 years and older who were hospitalized for abdominal cancer surgery between 2014 and 2018. Colon resections were the most common procedures (n = 1′690), followed by rectal resections (n = 709). For rectal, colon and pancreatic resections, an increase in the mean number of interventions per hospital and a reduction of low volume hospitals could be observed. For the relationship between hospital volume and outcomes, we did not observe a clear dose-response relationship, as no significantly better outcomes were observed in the higher-volume category than in the lower-volume category. Even though a positive “routine effect” cannot be excluded, our results suggest that even hospitals with low volumes are able to achieve comparable treatment outcomes to larger hospitals. Conclusion In summary, this study increases transparency on the relationship between hospital volume and treatment success. It shows that simple measures such as defining a minimum number of procedures only might not lead to the intended effects if other factors such as infrastructure, the operating team or aggregation level of the available data are not taken into account. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07513-5.
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16
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Lequeu JB, Cottenet J, Facy O, Perrin T, Bernard A, Quantin C. Failure to rescue in patients with distal pancreatectomy: a nationwide analysis of 10,632 patients. HPB (Oxford) 2021; 23:1410-1417. [PMID: 33622649 DOI: 10.1016/j.hpb.2021.02.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 02/01/2021] [Accepted: 02/02/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND FTR appears as a major cause of postoperative mortality (POM). Hospital volume has an impact on FTR in pancreatic surgery but no study has investigated this relationship more specifically in DP. METHODS We analysed patients with DP between 2009 and 2018 through a nationwide database. FTR definition was mortality among patients who experiment major complications. The cutoff between high and low volume centers was 20 pancreatectomies per year. RESULTS Some 10,632 patients underwent DP, 5048 (47.5%) were operated in 602 (95.4%) low volume centers and 5584 (52.5%) in 29 (4.6%) high volume centers. Overall FTR occurred in 11.2% of patients and was significantly reduced in high volume centers compared to low volume centers (10.2% vs 12.5%, p = 0.047). In multivariate analysis, surgery in a high volume center was a protective factor for POM (OR = 0.570, CI95% [0.505-0.643], p < 0.001) and also for FTR (OR = 0.550, CI95% [0.486-0.630], p < 0.001). CONCLUSION Hospital volume has a positive impact on FTR in DP. Patients with higher risk of FTR are men, with high modified Charlson comorbidity index, malignant conditions and open procedures.
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Affiliation(s)
- Jean-Baptiste Lequeu
- Dijon University Hospital, Department of Digestive Surgical Oncology, Dijon F-21000, France.
| | - Jonathan Cottenet
- Dijon University Hospital, Clinical Epidemiology/Clinical Trials Unit, Clinical Investigation Center, Dijon F-21000, France
| | - Olivier Facy
- Dijon University Hospital, Department of Digestive Surgical Oncology, Dijon F-21000, France
| | - Thomas Perrin
- Dijon University Hospital, Department of Digestive Surgical Oncology, Dijon F-21000, France
| | - Alain Bernard
- Dijon University Hospital, Department of Thoracic Surgery, Dijon F-21000, France
| | - Catherine Quantin
- Dijon University Hospital, Clinical Epidemiology/Clinical Trials Unit, Clinical Investigation Center, Dijon F-21000, France
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17
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Lam MB, Riley KE, Mehtsun W, Phelan J, Orav EJ, Jha AK, Burke LG. Association of Teaching Status and Mortality After Cancer Surgery. ANNALS OF SURGERY OPEN 2021; 2:e073. [PMID: 34458890 PMCID: PMC8389472 DOI: 10.1097/as9.0000000000000073] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 05/14/2021] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To examine patient outcomes for nine cancer-specific procedures performed in teaching versus non-teaching hospitals. SUMMARY BACKGROUND DATA Few contemporary studies have evaluated patient outcomes in teaching versus non-teaching hospitals across a comprehensive set of cancer-specific procedures. METHODS Use of national Medicare data to compare 30-, 60-, and 90-day mortality rates in teaching and non-teaching hospitals for cancer-specific procedures. Risk-adjusted 30-day, all-cause, postoperative mortality overall and for each specific surgery, as well as overall 60- and 90-day mortality rates, were assessed. RESULTS The sample consisted of 159,421 total cancer surgeries at 3,151 hospitals. Overall thirty-day mortality rates, adjusted for procedure type, state, and invasiveness of procedure were 1.3% lower at major teaching hospitals (95%CI=-1.6% to -1.1%; p<0.001) relative to non-teaching hospitals. After accounting for patient characteristics, major teaching hospitals continued to demonstrate lower mortality rates compared with non-teaching hospitals (-1.0% difference [95%CI -1.2% to -0.7%]; p<0.001). Further adjustment for surgical volume as a mediator reduced the difference to -0.7% (95%CI -0.9% to -0.4%, p<0.001). Cancer surgeries for four of the nine disease sites (bladder, lung, colorectal and ovarian) followed this overall trend. Sixty- and ninety-day overall mortality rates, adjusted for procedure type, state, and invasiveness of procedure showed that major teaching hospitals had a 1.7% (95%CI -2.1% to -1.4%; p<0.001) and 2.0% (95%CI -2.4 to -1.6%, p<0.001) lower mortality relative to non-teaching hospitals. These trends persisted after adjusting for patient characteristics. CONCLUSIONS Among cancer-specific procedures for Medicare beneficiaries, major teaching hospital status was associated with lower 30-, 60-, and 90-day mortality rates overall and across four of the nine cancer types.
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Affiliation(s)
- Miranda B. Lam
- From the Department of Health Policy and Management, Harvard School of Public Health, Boston, MA
- Department of Radiation Oncology, Brigham and Women’s Hospital/Dana Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Kristen E. Riley
- From the Department of Health Policy and Management, Harvard School of Public Health, Boston, MA
| | - Winta Mehtsun
- Harvard Medical School, Boston, MA
- Department of Surgery, Brigham and Women’s Hospital/Dana Farber Cancer Institute, Boston, MA
| | - Jessica Phelan
- From the Department of Health Policy and Management, Harvard School of Public Health, Boston, MA
| | - E. John Orav
- Harvard Medical School, Boston, MA
- Division of General Internal Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Ashish K. Jha
- Brown University School of Public Health, Providence, RI
| | - Laura G. Burke
- From the Department of Health Policy and Management, Harvard School of Public Health, Boston, MA
- Harvard Medical School, Boston, MA
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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18
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Nymo LS, Kleive D, Waardal K, Bringeland EA, Søreide JA, Labori KJ, Mortensen KE, Søreide K, Lassen K. Centralizing a national pancreatoduodenectomy service: striking the right balance. BJS Open 2020; 4:904-913. [PMID: 32893988 PMCID: PMC7528527 DOI: 10.1002/bjs5.50342] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/23/2020] [Accepted: 07/20/2020] [Indexed: 12/19/2022] Open
Abstract
Background Centralization of pancreatic surgery is currently called for owing to superior outcomes in higher‐volume centres. Conversely, organizational and patient concerns speak for a moderation in centralization. Consensus on the optimal balance has not yet been reached. This observational study presents a volume–outcome analysis of a complete national cohort in a health system with long‐standing centralization. Methods Data for all pancreatoduodenectomies in Norway in 2015 and 2016 were identified through a national quality registry and completed through electronic patient journals. Hospitals were dichotomized (high‐volume (40 or more procedures/year) or medium–low‐volume). Results Some 394 procedures were performed (201 in high‐volume and 193 in medium–low‐volume units). Major postoperative complications occurred in 125 patients (31·7 per cent). A clinically relevant postoperative pancreatic fistula occurred in 66 patients (16·8 per cent). Some 17 patients (4·3 per cent) died within 90 days, and the failure‐to‐rescue rate was 13·6 per cent (17 of 125 patients). In multivariable comparison with the high‐volume centre, medium–low‐volume units had similar overall complication rates, lower 90‐day mortality (odds ratio 0·24, 95 per cent c.i. 0·07 to 0·82) and no tendency for a higher failure‐to‐rescue rate. Conclusion Centralization beyond medium volume will probably not improve on 90‐day mortality or failure‐to‐rescue rates after pancreatoduodenectomy.
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Affiliation(s)
- L S Nymo
- Department of Gastrointestinal Surgery, University Hospital of North, Tromsø, Norway.,Institute of Clinical Medicine, Arctic University of Norway, Tromsø, Norway
| | - D Kleive
- Department of Hepatobiliary and Pancreatic Surgery, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - K Waardal
- Department of Gastrointestinal Surgery, Haukeland University Hospital, Bergen, Norway
| | - E A Bringeland
- Department of Gastrointestinal Surgery, St Olav Hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - J A Søreide
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - K J Labori
- Department of Hepatobiliary and Pancreatic Surgery, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - K E Mortensen
- Department of Gastrointestinal Surgery, University Hospital of North, Tromsø, Norway.,Institute of Clinical Medicine, Arctic University of Norway, Tromsø, Norway
| | - K Søreide
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway
| | - K Lassen
- Institute of Clinical Medicine, Arctic University of Norway, Tromsø, Norway.,Department of Hepatobiliary and Pancreatic Surgery, Oslo University Hospital, Oslo, Norway
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19
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Siegel J, Engelhardt KE, Hornor MA, Morgan KA, Lancaster WP. Travel distance and its interaction with patient and hospital factors in pancreas cancer care. Am J Surg 2020; 221:819-825. [PMID: 32891396 DOI: 10.1016/j.amjsurg.2020.08.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 07/24/2020] [Accepted: 08/21/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Although volume-outcome literature supports regionalization for complex procedures, travel may be burdensome. We assessed the relationship between overall survival and travel distance for patients undergoing pancreatic resection for adenocarcinoma. METHODS We analyzed the Fall 2018 National Cancer Database Public Use File. We defined distance traveled as a categorical variable (<12.5 miles, 12.5-50mi, and >50mi). We analyzed overall survival (OS) as a function of distance traveled using the log rank test and Cox proportional hazards models; we estimated stratified models to assess for interaction between distance and other relevant covariates. RESULTS In adjusted analysis of 39,089 patients, greater distance was associated with decreased OS (p = 0.0029). We found interactions between distance and center type, comorbidities, and age. Distance traveled was a negative factor for patients treated at low-volume academic centers (but not high-volume academic or non-academic centers). Additionally, distance traveled was a negative factor for OS in young, healthy patients but not geriatric, ill patients. CONCLUSION Traveling more than 12.5 miles for pancreatic resection was associated with worse OS. Prior to regionalization, evaluation of local resources may be necessary.
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Affiliation(s)
- Julie Siegel
- Department of Surgery, Medical University of South Carolina, 29 Jonathan Lucas St, Charleston, SC 29403, USA
| | - Kathryn E Engelhardt
- Department of Surgery, Medical University of South Carolina, 29 Jonathan Lucas St, Charleston, SC 29403, USA; Department of Surgery, Washington University in St. Louis, 1 Barnes Jewish Hospital Plaza, St. Louis, MO 63110, USA
| | - Melissa A Hornor
- Department of Surgery, Ohio State University, 410 W 10th Ave, Columbus, OH 43210, USA; Department of Surgery, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104, USA
| | - Katherine A Morgan
- Department of Surgery, Medical University of South Carolina, 29 Jonathan Lucas St, Charleston, SC 29403, USA
| | - William P Lancaster
- Department of Surgery, Medical University of South Carolina, 29 Jonathan Lucas St, Charleston, SC 29403, USA.
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20
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Mehta R, Paredes AZ, Tsilimigras DI, Moro A, Sahara K, Farooq A, Dillhoff M, Cloyd JM, Tsung A, Ejaz A, Pawlik TM. Influence of hospital teaching status on the chance to achieve a textbook outcome after hepatopancreatic surgery for cancer among Medicare beneficiaries. Surgery 2020; 168:92-100. [PMID: 32303348 DOI: 10.1016/j.surg.2020.02.024] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 01/13/2020] [Accepted: 02/26/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Assessing composite measures of quality such as textbook outcome may be superior to focusing on individual parameters when evaluating hospital performance. The aim of the current study was to assess the impact of teaching hospital status on the occurrence of a textbook outcome after hepatopancreatic surgery. METHODS The Medicare Inpatient Standard Analytic Files were used to identify patients undergoing hepatopancreatic surgery from 2013 to 2015 for a malignant indication. Stratified and multivariable regression analyses were performed to determine the relationship between teaching hospital status, hospital surgical volume and textbook outcome. RESULTS Among 8,035 Medicare patients (hepatectomy; 41.8%, pancreatectomy; 58.2%), 6,196 (77.1%) patients underwent surgery at a major teaching hospital, whereas 1,839 (22.9%) patients underwent surgery at a minor teaching hospital. Patients undergoing surgery for pancreatic cancer at a major teaching hospital had a greater likelihood of achieving a textbook outcome compared with patients treated at a minor teaching hospital (minor teaching hospital: 456, 40% versus major teaching hospital: 1,606, 45.4%; P = .002). The likelihood of textbook outcome was also greater among patients undergoing hepatopancreatic surgery at high-volume centers (pancreas, low volume: 875, 40.5% versus high volume: 1,187, 47.1% P < .001; liver, low volume: 608, 41.8% versus high volume: 886, 46.6%; P = .005). When examining only major teaching hospitals, patients undergoing a pancreatectomy at a high-volume center had 29% greater odds of achieving a textbook outcome (odds ratio 1.29, 95% confidence interval 1.12-1.49). In contrast, among patients undergoing pancreatic resection at high-volume centers, the odds of achieving a textbook outcome was comparable among major versus minor teaching hospital (odds ratio 1.17, 95% confidence interval 0.89-1.53). CONCLUSION The odds of achieving a textbook outcome after pancreatic and hepatic surgery was greater at major versus minor teaching hospitals; however, this effect was largely mediated by hepatopancreatic procedural volume. Patients and payers should focus on regionalization of pancreatic and liver resection to high-volume centers in an effort to optimize the chances of achieving a textbook outcome.
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Affiliation(s)
- Rittal Mehta
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Amika Moro
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Kota Sahara
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Ayesha Farooq
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Mary Dillhoff
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Jordan M Cloyd
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Allan Tsung
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Aslam Ejaz
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH.
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21
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Singh Y, Cawich SO, Mohammed S, Kuruvilla T, Naraynsingh V. Totally Laparoscopic Whipple's Operation: Initial Report from the Caribbean. Cureus 2020; 12:e7401. [PMID: 32337127 PMCID: PMC7182051 DOI: 10.7759/cureus.7401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Oncologic surgery in the Caribbean has evolved over the past decade, with increasing reports of advanced minimally invasive operations being performed. However, the minimally invasive approach has not been used for peri-ampullary lesions. This is because a laparoscopic Whipple's operation is a technically demanding and time-consuming operation. We report the first case of a totally laparoscopic Whipple's operation to be performed in the Caribbean.
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Affiliation(s)
- Yardesh Singh
- Surgery, University of the West Indies, St. Augustine, TTO
| | | | | | | | - Vijay Naraynsingh
- Surgery, Medical Associates Hospital, St. Joseph, TTO.,Clinical Surgical Sciences, University of the West Indies, St. Augustine, TTO
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22
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Ahola R, Sand J, Laukkarinen J. Centralization of Pancreatic Surgery Improves Results: Review. Scand J Surg 2020; 109:4-10. [DOI: 10.1177/1457496919900411] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background and Aims: The effect of operation volume on the outcomes of pancreatic surgery has been a subject of research since the 1990s. In several countries around the world, this has led to the centralization of pancreatic surgery. However, controversy persists as to the benefits of centralization and what the optimal operation volume for pancreatic surgery actually is. This review summarizes the data on the effect of centralization on mortality, complications, hospital facilities used, and costs regarding pancreatic surgery. Materials and Methods: A systematic librarian-assisted search was performed in PubMed covering the years from August 1999 to August 2019. All studies comparing results of open pancreatic resections from high- and low-volume centers were included. In total 44, published articles were analyzed. Results: Studies used a variety of different criteria for high-volume and low-volume centers, which hampers the evaluating of the effect of operation volume. However, mortality in high-volume centers is consistently reported to be lower than in low-volume centers. In addition, failure to rescue critically ill patients is more common in low-volume centers. Cost-effectiveness has also been evaluated in the literature. Length of hospital stay in particular has been reported to be shorter in high-volume centers than in low-volume centers. Conclusion: The effect of centralization on the outcomes of pancreatic surgery has been under active research and the beneficial effect of it is associated especially with better short-term prognosis after surgery.
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Affiliation(s)
- R. Ahola
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - J. Sand
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
- Tampere University Hospital, Tampere, Finland
| | - J. Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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Søreide K, Nymo LS, Lassen K. Centralization of Pancreatic Surgery in Europe: an Update. J Gastrointest Surg 2019; 23:2322-2323. [PMID: 31485907 DOI: 10.1007/s11605-019-04383-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 08/27/2019] [Indexed: 01/31/2023]
Affiliation(s)
- Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway. .,Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Linn S Nymo
- Department of Gastrointestinal Surgery, University Hospital of Northern Norway, Tromsø, Norway.,Institute of Clinical Medicine, The Arctic University of Norway, Tromsø, Norway
| | - Kristoffer Lassen
- Institute of Clinical Medicine, The Arctic University of Norway, Tromsø, Norway.,Department of Hepatobiliary and Pancreatic Surgery, Oslo University Hospital, Oslo, Norway
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Letter to Editor Reply to: "Centralization of Pancreatic Surgery in Europe: an Update". J Gastrointest Surg 2019; 23:2324-2325. [PMID: 31512102 DOI: 10.1007/s11605-019-04387-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 08/27/2019] [Indexed: 01/31/2023]
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Polonski A, Izbicki JR, Uzunoglu FG. Centralization of Pancreatic Surgery in Europe. J Gastrointest Surg 2019; 23:2081-2092. [PMID: 31037503 DOI: 10.1007/s11605-019-04215-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 03/20/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND The objective of this article is a review and an analysis of the current state of centralization of pancreatic surgery in Europe. Numerous recent publications demonstrate higher postoperative in-hospital mortality rates in low-volume clinics after pancreatic resection than previously assumed due to their not publishing significantly worse outcomes when compared to high-volume centres. Although the benefits of centralization of pancreatic surgery in high-volume centres have been demonstrated in many studies, numerous countries have so far failed to establish centralization in their respective health care systems. METHODS A systematic literature search of the Medline database for studies concerning centralization of pancreatic surgery in Europe was conducted. The studies were reviewed independently for previously defined inclusion and exclusion criteria. We included 14 studies with a total of 117,634 patients. All data were extracted from or provided by health insurance company or governmental registry databases. RESULTS Thirteen out of the 14 studies demonstrate an improvement in their respective outcome related to volume. Twelve studies showed a significantly lower postoperative mortality rate in the highest annual volume group in comparison to overall postoperative mortality rate in the whole patient cohort. CONCLUSION As the available data indicate, most European countries have so far failed to establish centralization of pancreatic surgery to high-volume centres due to numerous reasons. Considering a plateau in survival rates of patients undergoing treatment for pancreatic cancer in Europe during the last 15 years, this review enforces the worldwide plea for centralization to lower post-operative mortality after pancreatic surgery.
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Affiliation(s)
- Adam Polonski
- Department of General, Visceral and Thoracic Surgery, University Medical Centre, Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Centre, Hamburg-Eppendorf, Hamburg, Germany. .,Department of General Visceral and Thoracic Surgery, University of Hamburg Medical Institutions, Martinistr 52, 20252, Hamburg, Germany.
| | - Faik G Uzunoglu
- Department of General, Visceral and Thoracic Surgery, University Medical Centre, Hamburg-Eppendorf, Hamburg, Germany
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Failure-to-rescue in Patients Undergoing Pancreatectomy: Is Hospital Volume a Standard for Quality Improvement Programs? Nationwide Analysis of 12,333 Patients. Ann Surg 2019; 268:799-807. [PMID: 30048329 DOI: 10.1097/sla.0000000000002945] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate the influence of hospital volume on failure-to-rescue (FTR) after pancreatectomy in France. BACKGROUND There are growing evidences that FTR is an important source of postoperative mortality (POM) after pancreatectomy. However, few studies have analyzed the volume-FTR relationship following pancreatic surgery. METHODS All patients undergoing pancreatectomy between 2012 and 2015 were included. FTR is defined as the 90-day POM rate among patients with major complications. According to the spline model, the critical cutoff was 20 resections per year and hospitals were divided into low (<10 resections/an), intermediate (11-19 resections/yr), and high volume centers (≥20 resections/yr). RESULTS Overall, 12,333 patients who underwent pancreatectomy were identified. The POM was 6.9% and decreased significantly with increased hospital volume. The rate of FTR was 14.5% and varied significantly with hospital volume (18.3% in low hospital volume vs 11.9% in high hospital volume, P < 0.001), age (P < 0.001) and ChCl (CCl0-2: 11.5%, ChCl3: 13%, CCl ≥4:18.6%; P < 0.001). FTR for renal failure was the highest of all complications (40.2%), followed by postoperative shock (36.4%) and cardiac complications (35.1%). The FTR was significantly higher in low and intermediate compared with high volume hospitals for shock, digestive, and thromboembolic complications and reoperation. In multivariable analysis, intermediate (OR = 1.265, CI95%[1.103-1.701], P = 0.045) and low volume centers (OR = 1.536, CI95%[1.165-2.025], P = 0.002) were independently associated with increased FTR rates. CONCLUSION FTR after pancreatectomy is high and directly correlated to hospital volume, highlighting variability in the management of postoperative complications. Measurement of the FTR rate should become a standard for quality improvement programs.
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Nymo LS, Søreide K, Kleive D, Olsen F, Lassen K. The effect of centralization on short term outcomes of pancreatoduodenectomy in a universal health care system. HPB (Oxford) 2019; 21:319-327. [PMID: 30297306 DOI: 10.1016/j.hpb.2018.08.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 08/21/2018] [Accepted: 08/29/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Centralization of pancreatic resections is advocated due to a volume-outcome association. Pancreatic surgery is in Norway currently performed only in five teaching hospitals. The aim was to describe the short-term outcomes after pancreatoduodenectomy (PD) within the current organizational model and to assess for regional disparities. METHODS All patients who underwent PD in Norway between 2012 and 2016 were identified. Mortality (90 days) and relaparotomy (30 days) were assessed for predictors including demographic data and multi-visceral or vascular resection. Aggregated length-of-stay and national and regional incidences of the procedure were also analysed. RESULTS A total of 930 patients underwent PD during the study period. In-hospital mortality occurred in 20 patients (2%) and 34 patients (4%) died within 90 days. Male gender, age, multi-visceral resection and relaparotomy were independent predictors of 90-day mortality. Some 131 patients (14%) had a relaparotomy, with male gender and multi-visceral resection as independent predictors. There was no difference between regions in procedure incidence or 90-day mortality. There was a disparity within the regions in the use of vascular resection (p = 0.021). CONCLUSION The short-term outcomes after PD in Norway are acceptable and the 90-day mortality rate is low. The outcomes may reflect centralization of pancreatic surgery.
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Affiliation(s)
- Linn S Nymo
- Department of Gastrointestinal Surgery, University Hospital of Northern Norway, Sykehusveien 38, 9019, Tromsø, Norway; Institute of Clinical Medicine, The Arctic University of Norway, Hansine Hansens Veg 18, 9019, Tromsø, Norway.
| | - Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Postboks 8100, 4068, Stavanger, Norway; Clinical Surgery, Royal Infirmary of Edinburgh and University of Edinburgh, 51 Little France Cres, Edinburgh, EH16 4SA, UK; Department of Clinical Medicine, University of Bergen, Jonas Lies Vei 65, 5021, Bergen
| | - Dyre Kleive
- Department of Hepatobiliary and Pancreatic Surgery, Oslo University Hospital, Postboks 4950 Nydalen, 0424, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Problemveien 7, 0315, Oslo, Norway
| | - Frank Olsen
- Centre for Clinical Documentation and Evaluation (SKDE), Northern Norway Regional Health Authority, Sykehusveien 38, 9019, Tromsø, Norway
| | - Kristoffer Lassen
- Department of Gastrointestinal Surgery, University Hospital of Northern Norway, Sykehusveien 38, 9019, Tromsø, Norway; Institute of Clinical Medicine, The Arctic University of Norway, Hansine Hansens Veg 18, 9019, Tromsø, Norway; Department of Hepatobiliary and Pancreatic Surgery, Oslo University Hospital, Postboks 4950 Nydalen, 0424, Oslo, Norway
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Antila A, Ahola R, Sand J, Laukkarinen J. Management of postoperative complications may favour the centralization of distal pancreatectomies. Nationwide data on pancreatic distal resections in Finland 2012-2014. Pancreatology 2019; 19:26-30. [PMID: 30522826 DOI: 10.1016/j.pan.2018.11.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 11/22/2018] [Accepted: 11/23/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Centralization of pancreatic surgery has proceeded in the last few years in many countries. However, information on the effect of hospital volume specifically on distal pancreatic resections (DP) is lacking. AIM To investigate the effect of hospital volume on postoperative complications in DP patients in Finland. METHODS All DP performed in Finland during the period 2012-2014 were analyzed, information having been retrieved from the appropriate national registers. Hospital volumes, postoperative pancreatic fistulae (POPF) and overall complications were graded. High volume centre (HVC) was defined as performing > 10 DPs, median volume centre (MVC) 4-9 DPs and low volume centre (LVC) fewer than 4 DP annually. RESULTS A total of 194 DPs were performed at 18 different hospitals. Of these 42% (81) were performed in HVCs (2 hospitals), 43% (84) in MVCs (6 hospitals) and the remaining 15% (29) in LVCs (10 hospitals). Patient demographics did not differ between the hospital volume groups. The overall rate of clinically relevant POPF, Clavien-Dindo grade 3-5 complications, and 90-day mortality showed no significant differences between the different hospital volumes. Grade C POPF was found more often in LVCs, being 1.2% in HVCs, 0% in MCVs and 6.9% in LVCs, p = 0.030. More reoperations were performed in LVCs (10.3%) than in HVCs (1.2%) or MVCs (1.2%); p = 0.025. CONCLUSIONS Even though the rate of postoperative complications after DP is not affected by hospital volume, reoperations were performed ten times more often in the low-volume centres. Optimal management of postoperative complications may favour centralization not only of PD, but also of DP.
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Affiliation(s)
- A Antila
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - R Ahola
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - J Sand
- Päijät-Häme Central Hospital, Lahti, Finland
| | - J Laukkarinen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland; Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland.
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Raoof M, Zafar SN, Ituarte PHG, Krouse RS, Melstrom K. Using a Lymph Node Count Metric to Identify Underperforming Hospitals After Rectal Cancer Surgery. J Surg Res 2018; 236:216-223. [PMID: 30694758 DOI: 10.1016/j.jss.2018.11.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 10/13/2018] [Accepted: 11/20/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Investigating methods to assess the quality of cancer surgery and then benchmarking hospitals on these quality indicators can lead to improvements in cancer care in the United States. We sought to determine the utility of lymph node count as a quality metric. METHODS We performed a retrospective analysis of the California Cancer Registry database (2004-2011) merged with Office of Statewide Health Planning and Development inpatient database. Patients with locally advanced rectal adenocarcinoma who underwent neoadjuvant therapy and resection were included. Hospital quality score was defined as the proportion of patients at a particular hospital that had adequate examination with at least nine lymph nodes. High-quality score hospitals were those that retrieved nine or more nodes among ≥25% of operations. A multivariate Cox proportional hazards (standard and shared frailty) model was used to determine differences in overall survival adjusting for age, hospital volume, race, sex, insurance, comorbidity, T-stage, response to neoadjuvant therapy, adjuvant chemotherapy, and teaching hospital status as covariates. RESULTS A total of 2704 patients were treated at 228 hospitals (low-scoring hospital = 85 and high-scoring hospital = 143). Patient- and disease-specific characteristics were similar between the groups. Socioeconomic status and hospital characteristics were strongly associated with score status. High-scoring hospitals had higher sphincter preservation (P = 0.004), lower complications (P = 0.021), and a trend toward lower mortality (P = 0.079). Care at high-scoring hospitals independently predicted overall survival (hazard ratio: 0.74; 95% confidence interval: 0.61-0.90; P = 0.003). CONCLUSIONS This study demonstrates that hospital quality score based on lymph node count can be used to identify underperforming hospitals.
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Affiliation(s)
- Mustafa Raoof
- Department of Surgery, City of Hope National Medical Center, Duarte, California.
| | - Syed Nabeel Zafar
- Department of Surgery, MD Anderson Cancer Center, Howard University, Washington, DC, Houston Texas
| | - Philip H G Ituarte
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Robert S Krouse
- Department of Surgery, University of Pennsylvania and Surgical Service Line, Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Kurt Melstrom
- Department of Surgery, City of Hope National Medical Center, Duarte, California
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Complex distal pancreatectomy outcomes performed at a single institution. Surg Oncol 2018; 27:428-432. [DOI: 10.1016/j.suronc.2018.05.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 05/24/2018] [Accepted: 05/28/2018] [Indexed: 01/08/2023]
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Castel-Kremer E, De Talhouet S, Charlois AL, Graillot E, Chopin-Laly X, Adham M, Comte B, Lombard-Bohas C, Walter T, Boschetti G. An onco-geriatric approach to select older patients for optimal treatments of pancreatic adenocarcinoma. J Geriatr Oncol 2018; 9:373-381. [DOI: 10.1016/j.jgo.2018.03.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 01/23/2018] [Accepted: 03/13/2018] [Indexed: 12/20/2022]
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Abstract
BACKGROUND To assess feasibility, safety, and metabolic outcome of islet auto transplantation (IAT) in patients undergoing completion pancreatectomy because of sepsis or bleeding after pancreatic surgery. METHODS From November 2008 to October 2016, approximately 22 patients were candidates to salvage IAT during emergency relaparotomy because of postpancreatectomy sepsis (n = 11) or bleeding (n = 11). Feasibility, efficacy, and safety of salvage IAT were compared with those documented in a cohort of 36 patients who were candidate to simultaneous IAT during nonemergency preemptive completion pancreatectomy through the pancreaticoduodenectomy. RESULTS The percentage of candidates that received the infusion of islets was significantly lower in salvage IAT than simultaneous IAT (59.1% vs 88.9%, P = 0.008), mainly because of a higher rate of inadequate islet preparations. Even if microbial contamination of islet preparation was significantly higher in candidates to salvage IAT than in those to simultaneous IAT (78.9% vs 20%, P < 0.001), there was no evidence of a higher rate of complications related to the procedure. Median follow-up was 5.45 ± 0.52 years. Four (36%) of 11 patients reached insulin independence, 6 patients (56%) had partial graft function, and 1 patient (9%) had primary graft nonfunction. At the last follow-up visit, median fasting C-peptide was 0.43 (0.19-0.93) ng/mL; median insulin requirement was 0.38 (0.04-0.5) U/kg per day, and median HbA1c was 6.6% (5.9%-8.1%). Overall mortality, in-hospital mortality, metabolic outcome, graft survival, and insulin-free survival after salvage IAT were not different from those documented after simultaneous IAT. CONCLUSIONS Our data demonstrate the feasibility, efficacy, and safety of salvage IAT after relaparotomy.
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Rovers KP, Simkens GA, Vissers PA, Lemmens VE, Verwaal VJ, Bremers AJ, Wiezer MJ, Burger JW, Hemmer PH, Boot H, van Grevenstein WM, Meijerink WJ, Aalbers AG, Punt CJ, Tanis PJ, de Hingh IH. Survival of patients with colorectal peritoneal metastases is affected by treatment disparities among hospitals of diagnosis: A nationwide population-based study. Eur J Cancer 2017; 75:132-140. [PMID: 28222307 DOI: 10.1016/j.ejca.2016.12.034] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 11/24/2016] [Accepted: 12/11/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND In the Netherlands, surgery for peritoneal metastases of colorectal cancer (PMCRC) is centralised, whereas PMCRC is diagnosed in all hospitals. This study assessed whether hospital of diagnosis affects treatment selection and overall survival (OS). METHODS Between 2005 and 2015, all patients with synchronous PMCRC without systemic metastases were selected from the Netherlands Cancer Registry. Treatment was classified as cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC), systemic therapy or other/no treatment. Hospitals of diagnosis were classified as: (1) non-teaching or academic/teaching hospital and (2) HIPEC centre or referring hospital. Referring hospitals were further classified based on the frequency of CRS/HIPEC as high-, medium- or low-frequency hospital. Multivariable regression analyses were used to assess the independent influence of hospital categories on the likelihood of CRS/HIPEC and OS. RESULTS A total of 2661 patients, diagnosed in 89 hospitals, were included. At individual hospital level, CRS/HIPEC and systemic therapy ranged from 0% to 50% and 6% to 67%, respectively. Hospital of diagnosis influenced the likelihood of CRS/HIPEC: 33% versus 13% for HIPEC centres versus referring hospitals (odds ratio (OR) 3.66 [2.40-5.58]) and 11% versus 17% for non-teaching hospitals versus academic/teaching hospitals (OR 0.60 [0.47-0.77]). Hospital of diagnosis affected median OS: 14.1 versus 9.6 months for HIPEC centres versus referring hospitals (hazard ratio (HR) 0.82 [0.67-0.99]) and 8.7 versus 11.5 months for non-teaching hospitals versus academic/teaching hospitals (HR 1.15 [1.06-1.26]). Compared with diagnosis in medium-frequency referring hospitals, median OS was increased in high-frequency referring hospitals (12.6 months, HR 0.82 [0.73-0.91]) and reduced in low-frequency referring hospitals (8.1 months, HR 1.12 [1.01-1.24]). CONCLUSION Treatment disparities among hospitals of diagnosis and their impact on survival indicate suboptimal treatment selection for PMCRC.
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Affiliation(s)
- Koen P Rovers
- Department of Surgery, Catharina Hospital, PO Box 1350, 5602 ZA, Eindhoven, The Netherlands
| | - Geert A Simkens
- Department of Surgery, Catharina Hospital, PO Box 1350, 5602 ZA, Eindhoven, The Netherlands
| | - Pauline A Vissers
- Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), PO Box 19079, 3501 DB, Utrecht, The Netherlands
| | - Valery E Lemmens
- Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), PO Box 19079, 3501 DB, Utrecht, The Netherlands; Department of Public Health, Erasmus Medical Centre, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Victor J Verwaal
- Department of Surgery, Aarhus University Hospital, Norrebrogade 44, DK-8000, Aarhus, Denmark
| | - Andre J Bremers
- Department of Surgery, Radboud University Medical Centre, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Marinus J Wiezer
- Department of Surgery, Sint Antonius Hospital, PO Box 2500, 3430 EM, Nieuwegein, The Netherlands
| | - Jacobus W Burger
- Department of Surgery, Erasmus Medical Centre, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Patrick H Hemmer
- Department of Surgery, University Medical Centre Groningen, PO Box 30001, 9700 RB, Groningen, The Netherlands
| | - Henk Boot
- Department of Gastroenterology and Hepatology, Antoni van Leeuwenhoek Hospital, PO Box 90203, 1006 BE, Amsterdam, The Netherlands
| | | | - Wilhelmus J Meijerink
- Department of Surgery, VU University Medical Centre, PO Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - Arend G Aalbers
- Department of Surgery, Antoni van Leeuwenhoek Hospital, PO Box 90203, 1006 BE, Amsterdam, The Netherlands
| | - Cornelis J Punt
- Department of Medical Oncology, Academic Medical Centre, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - Pieter J Tanis
- Department of Surgery, Academic Medical Centre, PO Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, PO Box 1350, 5602 ZA, Eindhoven, The Netherlands.
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Altieri MS, Yang J, Yin D, Frenkel C, Talamini M, Telem DA, Pryor A. Presence of a fellowship improves perioperative outcomes following hepatopancreatobiliary procedures. Surg Endosc 2016; 31:2918-2924. [PMID: 27815743 DOI: 10.1007/s00464-016-5306-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 10/24/2016] [Indexed: 11/28/2022]
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Søreide K, Labori KJ. Risk factors and preventive strategies for post-operative pancreatic fistula after pancreatic surgery: a comprehensive review. Scand J Gastroenterol 2016; 51:1147-54. [PMID: 27216233 PMCID: PMC4975078 DOI: 10.3109/00365521.2016.1169317] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Pancreas surgery has developed into a fairly safe procedure in terms of mortality, but is still hampered by considerable morbidity. Among the most frequent and dreaded complications are the development of a post-operative pancreatic fistula (POPF). The prediction and prevention of POPF remains an area of debate with several questions yet to be firmly addressed with solid answers. METHODS A systematic review of systematic reviews/meta-analyses and randomized trials in the English literature (PubMed/MEDLINE, Cochrane library, EMBASE) covering January 2005 to December 2015 on risk factors and preventive strategies for POPF. RESULTS A total of 49 systematic reviews and meta-analyses over the past decade discussed patient, surgeon, pancreatic disease and intraoperative related factors of POPF. Non-modifiable factors (age, BMI, comorbidity) and pathology (histotype, gland texture, duct size) that indicates surgery are associated with POPF risk. Consideration of anastomotic technique and use of somatostatin-analogs may slightly modify the risk of fistula. Sealant products appear to have no effect. Perioperative bleeding and transfusion enhance risk, but is modifiable by focus on technique and training. Drains may not prevent fistulae, but may help in early detection. Early drain-amylase may aid in detection. Predictive scores lack uniform validation, but may have a role in patient information if reliable pre-operative risk factors can be obtained. CONCLUSIONS Development of POPF occurs through several demonstrated risk factors. Anastomotic technique and use of somatostatin-analogs may slightly decrease risk. Drains may aid in early detection of leaks, but do not prevent POPF.
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Affiliation(s)
- Kjetil Søreide
- Department of Gastrointestinal Surgery, HPB Unit, Stavanger University Hospital,
Stavanger,
Norway,Department of Clinical Medicine, University of Bergen,
Bergen,
Norway,CONTACT Kjetil Søreide
Department of Gastrointestinal Surgery, Stavanger University Hospital, POB 8100,
N-4068Stavanger,
Norway
| | - Knut Jørgen Labori
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital,
Oslo,
Norway
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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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Abstract
OBJECTIVES Structured follow-up after surgery for pancreatic ductal adenocarcinoma (PDAC) remains controversial and is currently not recommended due to a supposed lack of therapeutic consequences. Furthermore, it is not clear whether noncancer patients after pancreas resection need to be seen in the clinic on a regular basis. The present study analyzed how follow-up after pancreatic surgery affected postoperative treatment and long-term outcomes. METHODS Data of all postoperative visits in a specialized outpatient clinic for pancreatic diseases were analyzed for a 1-year period with regard to symptoms, diagnostic procedures, and therapeutic consequences. RESULTS Six hundred eighteen patients underwent 940 postoperative follow-ups. Nearly half of them needed a change of medication due to altered pancreatic function. In 74 (40%) of 184 resected PDAC patients, recurrence (local or systemic) was detected during follow-up, although only 19 of these had shown associated symptoms (26%). In all patients with recurrence, a cancer-directed treatment was induced. Eleven (69%) of 16 patients with isolated local recurrence were referred for reresection. CONCLUSIONS Follow-up examinations are a substantial part of the clinical management after pancreas resections. Follow-up is particularly important for PDAC because recurrence is often asymptomatic, but its detection allows for therapeutic interventions and potentially improved prognosis. This should be implemented in future guidelines.
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Balzano G, Maffi P, Nano R, Mercalli A, Melzi R, Aleotti F, Zerbi A, De Cobelli F, Gavazzi F, Magistretti P, Scavini M, Peccatori J, Secchi A, Ciceri F, Del Maschio A, Falconi M, Piemonti L. Autologous Islet Transplantation in Patients Requiring Pancreatectomy: A Broader Spectrum of Indications Beyond Chronic Pancreatitis. Am J Transplant 2016; 16:1812-26. [PMID: 26695701 DOI: 10.1111/ajt.13656] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 11/24/2015] [Accepted: 11/26/2015] [Indexed: 01/25/2023]
Abstract
Islet autotransplantation (IAT) is usually performed in patients undergoing pancreatic surgery for chronic pancreatitis. In the present series, IAT was offered also to patients undergoing pancreatic surgery for both nonmalignant and malignant diseases, having either completion pancreatectomy as treatment for severe pancreatic fistulas (n = 21) or extensive distal pancreatectomy for neoplasms of the pancreatic neck (n = 19) or pancreatoduodenectomy because of the high risk of pancreatic fistula (n = 32). Fifty-eight of 72 patients who were eligible to this broader spectrum of indication actually received IAT. There was no evidence of a higher-than-expected rate of major complications for pancreatectomy. Forty-five patients receiving IAT were still alive at the time of the last scheduled follow-up (1375 ± 365 days). Eighteen (95%) of 19 and 11 (28%) of 39 patients reached insulin independence after partial or total pancreatectomy, respectively. The metabolic results were dependent on the transplanted islet mass. Thirty-one of 58 patients had malignant diseases of the pancreas or periampullary region, and only three patients developed ex novo liver metastases after IAT (median follow-up 914 ± 382 days). Our data demonstrate the feasibility, efficacy, and safety of IAT for a broader spectrum of clinical indications beyond chronic pancreatitis.
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Affiliation(s)
- G Balzano
- Pancreatic Surgery Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - P Maffi
- Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - R Nano
- Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - A Mercalli
- Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - R Melzi
- Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - F Aleotti
- Pancreatic Surgery Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - A Zerbi
- Pancreatic Surgery Section, Department of General Surgery, IRCCS Istituto Clinico Humanitas, Milano, Italy
| | - F De Cobelli
- Department of Radiology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - F Gavazzi
- Pancreatic Surgery Section, Department of General Surgery, IRCCS Istituto Clinico Humanitas, Milano, Italy
| | - P Magistretti
- Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - M Scavini
- Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - J Peccatori
- Units of Haematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - A Secchi
- Clinical Transplant Unit, Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - F Ciceri
- Units of Haematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - A Del Maschio
- Department of Radiology, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - M Falconi
- Pancreatic Surgery Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - L Piemonti
- Diabetes Research Institute, IRCCS San Raffaele Scientific Institute, Milan, Italy
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