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Kotecha K, Tree K, Ziaziaris WA, McKay SC, Wand H, Samra J, Mittal A. Centralization of Pancreaticoduodenectomy: A Systematic Review and Spline Regression Analysis to Recommend Minimum Volume for a Specialist Pancreas Service. Ann Surg 2024; 279:953-960. [PMID: 38258578 DOI: 10.1097/sla.0000000000006208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
OBJECTIVE Through a systematic review and spline curve analysis, to better define the minimum volume threshold for hospitals to perform (pancreaticoduodenectomy) and the high-volume center. BACKGROUND The pancreaticoduodenectomy (PD) is a resource-intensive procedure, with high morbidity and long hospital stays resulting in centralization towards high-volume hospitals; the published definition of high volume remains variable. MATERIALS AND METHODS Following a systematic review of studies comparing PD outcomes across volume groups, semiparametric regression modeling of morbidity (%), mortality (%), length of stay (days), lymph node harvest (number of nodes), and cost ($USD) as continuous variables were performed and fitted as a smoothed function of splines. If this showed a nonlinear association, then a "zero-crossing" technique was used, which produced "first and second derivatives" to identify volume thresholds. RESULTS Our analysis of 33 cohort studies (198,377 patients) showed 55 PDs/year and 43 PDs/year were the threshold value required to achieve the lowest morbidity and highest lymph node harvest, with model estimated df 5.154 ( P <0.001) and 8.254 ( P <0.001), respectively. The threshold value for mortality was ~45 PDs/year (model 9.219 ( P <0.001)), with the lowest mortality value (the optimum value) at ~70 PDs/year (ie, a high-volume center). No significant association was observed for cost ( edf =2, P =0.989) and length of stay ( edf =2.04, P =0.099). CONCLUSIONS There is a significant benefit from the centralization of PD, with 55 PDs/year and 43 PDs/year as the threshold value required to achieve the lowest morbidity and highest lymph node harvest, respectively. To achieve mortality benefit, the minimum procedure threshold is 45 PDs/year, with the lowest and optimum mortality value (ie, a high-volume center) at approximately 70 PDs/year.
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Affiliation(s)
- Krishna Kotecha
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Kevin Tree
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - William A Ziaziaris
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Siobhan C McKay
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Institute of Cancer and Genomic Science, University of Birmingham, Edgbaston, Birmingham United Kingdom
| | - Handan Wand
- Kirby Institute (formerly National Center in HIV Epidemiology and Clinical Research), University of New South Wales, Sydney, NSW
| | - Jaswinder Samra
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia
- Australian Pancreatic Center, Sydney, Australia
| | - Anubhav Mittal
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia
- Australian Pancreatic Center, Sydney, Australia
- University of Notre Dame, Sydney
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Saadat LV, Wei AC. ASO Author Reflections: Improving Outcomes and Minimizing Variability in Pancreatic Cancer Care: A Study of Ontario and the United States. Ann Surg Oncol 2024; 31:1937-1938. [PMID: 37865939 DOI: 10.1245/s10434-023-14463-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 10/02/2023] [Indexed: 10/24/2023]
Affiliation(s)
- Lily V Saadat
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alice C Wei
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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3
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Saadat LV, Schofield E, Bai X, Curry M, Saskin R, Lipitz-Snyderman A, Soares KC, Kingham TP, Jarnagin WR, D'Angelica MI, Wright FC, Irish JC, Coburn NG, Wei AC. Treatment Patterns and Outcomes in Pancreatic Cancer: A Comparative Analysis of Ontario and the USA. Ann Surg Oncol 2024; 31:58-65. [PMID: 37833463 DOI: 10.1245/s10434-023-14375-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 09/15/2023] [Indexed: 10/15/2023]
Abstract
BACKGROUND Comparative studies evaluating quality of care in different healthcare systems can guide reform initiatives. This study seeks to characterize best practices by comparing utilization and outcomes for patients with pancreatic cancer (PC) in the USA and Ontario, Canada. METHODS Patients (age ≥ 66 years) with PC were identified from the Ontario Cancer Registry and SEER-Medicare databases from 2006 to 2015. Demographics and treatment (surgery, radiation, chemotherapy, or multimodality (surgery and chemotherapy)) were described. In resected patients, neoadjuvant therapy, readmission, and 30- and 90-day postoperative mortality rates were calculated. Survival was assessed using Kaplan-Meier curves. RESULTS This study includes 38,858 and 11,512 patients with PC from the USA and Ontario, respectively. More female patients were identified in the USA (54.0%) versus Ontario (46.9%). In the entire cohort, US patients received more radiation in addition to other therapies (18.8% vs. 13.5% Ontario) and chemotherapy alone (34.3% vs. 19.0% Ontario). While rates of resection were similar (13.4% USA vs.12.5% Ontario), multimodality therapy was more common in the UAS (9.0% vs. 6.4%). Among resected patients, neoadjuvant chemotherapy was uncommon in both groups, although more frequent in the USA (12.0% vs. 3.2% Ontario). The 30- and 90-day postoperative mortality rates were lower in Ontario vs. the USA (30-day: 3.26% vs. 4.91%; 90-day: 7.08% vs. 10.96%), however, overall survival was similar between the USA and Ontario. CONCLUSIONS We observed substantive differences in treatment and outcomes between PC patients in the USA and Ontario, which may reflect known differences in healthcare systems. Close evaluation of healthcare policies can inform initiatives to improve care quality.
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Affiliation(s)
- Lily V Saadat
- Division of Hepatopancreatobiliary, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Elizabeth Schofield
- Department of Psychiatry and Behavioral Services, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Xing Bai
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michael Curry
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Refik Saskin
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Allison Lipitz-Snyderman
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kevin C Soares
- Division of Hepatopancreatobiliary, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - T Peter Kingham
- Division of Hepatopancreatobiliary, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - William R Jarnagin
- Division of Hepatopancreatobiliary, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michael I D'Angelica
- Division of Hepatopancreatobiliary, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Frances C Wright
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Jonathan C Irish
- Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Natalie G Coburn
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Alice C Wei
- Division of Hepatopancreatobiliary, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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4
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Gao TP, Green RL, Kuo LE. Disparities in Access to High-Volume Surgeons and Specialized Care. Endocrinol Metab Clin North Am 2023; 52:689-703. [PMID: 37865482 DOI: 10.1016/j.ecl.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
Abstract
The significant volume-outcome relationship has triggered interest in improving quality of care by directing patients to high-volume centers and surgeons. However, significant disparities exist for different racial/ethnic, geographic, and socioeconomic groups for thyroid, parathyroid, adrenal, and pancreatic neuroendocrine surgical diseases disease.
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Affiliation(s)
- Terry P Gao
- Department of General Surgery, Temple University Hospital, 3401 North Broad Street, Zone C, 4th Floor, Philadelphia, PA 19140, USA
| | - Rebecca L Green
- Department of General Surgery, Temple University Hospital, 3401 North Broad Street, Zone C, 4th Floor, Philadelphia, PA 19140, USA
| | - Lindsay E Kuo
- Department of General Surgery, Temple University Hospital, 3401 North Broad Street, Zone C, 4th Floor, Philadelphia, PA 19140, USA.
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Kemp Bohan PM, Chang SC, Grunkemeier GL, Spitzer HV, Carpenter EL, Adams AM, Vreeland TJ, Nelson DW. Impact of Mediating and Confounding Variables on the Volume-Outcome Association in the Treatment of Pancreatic Cancer. Ann Surg Oncol 2023; 30:1436-1448. [PMID: 36460898 DOI: 10.1245/s10434-022-12908-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 10/28/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND High-volume centers (HVC), academic centers (AC), and longer travel distances (TD) have been associated with improved outcomes for patients undergoing surgery for pancreatic adenocarcinoma (PAC). Effects of mediating variables on these associations remain undefined. The purpose of this study is to examine the direct effects of hospital volume, facility type, and travel distance on overall survival (OS) in patients undergoing surgery for PAC and characterize the indirect effects of patient-, disease-, and treatment-related mediating variables. PATIENTS AND METHODS Using the National Cancer Database, patients with non-metastatic PAC who underwent resection were stratified by annual hospital volume (< 11, 11-19, and ≥ 20 cases/year), facility type (AC versus non-AC), and TD (≥ 40 versus < 40 miles). Associations with survival were evaluated using multiple regression models. Effects of mediating variables were assessed using mediation analysis. RESULTS In total, 19,636 patients were included. Treatment at HVC or AC was associated with lower risk of death [hazard ratio (HR) 0.90, confidence interval (CI) 0.88-0.92; HR 0.89, CI 0.86-0.91, respectively]. TD did not impact OS. Patient-, disease-, and treatment-related variables explained 25.5% and 41.8% of the survival benefit attained from treatment at HVC and AC, reducing the survival benefit directly attributable to each variable to 4.9% and 6.4%, respectively. CONCLUSIONS Treatment of PAC at HVC and AC was associated with improved OS, but the magnitude of this benefit was less when mediating variables were considered. From a healthcare utilization and cost-resource perspective, further research is needed to identify patients who would benefit most from selective referral to HVC or AC.
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Affiliation(s)
| | - Shu-Ching Chang
- Center for Cardiovascular Analytics, Research and Data Science (CARDS), Portland, OR, USA
| | - Gary L Grunkemeier
- Center for Cardiovascular Analytics, Research and Data Science (CARDS), Portland, OR, USA
| | - Holly V Spitzer
- Department of Surgery, William Beaumont Army Medical Center, Fort Bliss, TX, USA
| | | | - Alexandra M Adams
- Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Timothy J Vreeland
- Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Daniel W Nelson
- Department of Surgery, William Beaumont Army Medical Center, Fort Bliss, TX, USA.
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Fischer C, Alvarico SJ, Wildner B, Schindl M, Simon J. The relationship of hospital and surgeon volume indicators and post-operative outcomes in pancreatic surgery: a systematic literature review, meta-analysis and guidance for valid outcome assessment. HPB (Oxford) 2023; 25:387-399. [PMID: 36813680 DOI: 10.1016/j.hpb.2023.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 01/12/2023] [Accepted: 01/18/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Available evidence on the volume-outcome relationship after pancreatic surgery is limited due to the narrow focus of interventions, volume indicators and outcomes considered as well as due to methodological differences of the included studies. Therefore, we aim to evaluate the volume-outcome relationship following pancreatic surgery following strict study selection and quality criteria, to identify aspects of methodological variation and to define a set of key methodological indicators to consider when aiming for comparable and valid outcome assessment. METHODS Four electronic databases were searched to identify studies on the volume-outcome relationship in pancreatic surgery published between the years 2000-2018. Following a double-screening process, data extraction, quality appraisal, and subgroup analysis, results of included studies were stratified and pooled using random effects meta-analysis. RESULTS Consistent associations were found between high hospital volume and both postoperative mortality (OR 0.35, 95% CI: 0.29-0.44) and major complications (OR 0.87, 95% CI: 0.80-0.94). A significant decrease in the odds ratio was also found for high surgeon volume and postoperative mortality (OR 0.29, 95%CI: 0.22-0.37). DISCUSSION Our meta-analysis confirms a positive effect for both hospital and surgeon volume indicators for pancreatic surgery. Further harmonization (e.g. surgery types, volume cut-offs/definition, case-mix adjustment, reported outcomes) are recommended for future empirical studies.
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Affiliation(s)
- Claudia Fischer
- Department of Health Economics, Center for Public Health, Medical University of Vienna, Vienna, Austria.
| | - Stefanie J Alvarico
- Department of Health Economics, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - B Wildner
- University Library, Medical University of Vienna, Vienna, Austria
| | - Martin Schindl
- Department of Surgery, Comprehensive Cancer Center (CCC), Medical University and Pancreatic Cancer Unit, Vienna, Austria
| | - Judit Simon
- Department of Health Economics, Center for Public Health, Medical University of Vienna, Vienna, Austria; Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, United Kingdom; Ludwig Boltzmann Institute Applied Diagnostics, Vienna, Austria
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7
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Zhu L, Li T, Yang Y, Tang N, Fu X, Qiu Y. Development and validation of a nomogram for predicting post-operative abdominal infection in patients undergoing pancreaticoduodenectomy. Clin Chim Acta 2022; 534:57-64. [PMID: 35835202 DOI: 10.1016/j.cca.2022.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 06/21/2022] [Accepted: 07/04/2022] [Indexed: 11/03/2022]
Abstract
AIM The aim of this retrospective study is to develop and validate a predictive nomogram for predicting the risk of post-operative abdominal infection (PAI) in patients undergoing pancreaticoduodenectomy (PD). METHODS A total of 360 patients who underwent PD were enrolled into this research and randomly divided into the development and validation group. The clinical data of patients were statistically compared and the nomogram was constructed based on the results of multivariate logistic regression analysis and stepwise (stepAIC) selection. The nomogram was internally and crossly validated by the development and validation cohort. The discriminatory ability of the nomogram was estimated by AUC (Area Under the receiver operating characteristic Curve), calibration curve and decision curve analysis. RESULTS After PD, post-operative abdominal infection occurred in 33.89% (n = 122) of patients. The nomogram showed that preoperative biliary drainage and C-reactive protein (CRP), direct bilirubin (DB), alkaline phosphatase (AKP) levels on the 3rd postoperative day (POD3) were independent prognostic factors for abdominal infection after PD. The internal and cross validation of Receiver Operating Characteristic (ROC) curve was statistically significant (AUC = 0.723 and 0.786, respectively). The calibration curves showed good agreement between nomogram predictions and actual observations. The decision curves showed that the nomogram was of great clinical value. CONCLUSION A nomogram based on perioperative risk factors such as preoperative biliary drainage, CRP, DB and AKP could simply and accurately predict the risk degree of PAI in patients undergoing PD.
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Affiliation(s)
- Linxi Zhu
- Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Taishun Li
- Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Yifei Yang
- Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Neng Tang
- Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Xu Fu
- Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China.
| | - Yudong Qiu
- Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China.
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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: 15] [Impact Index Per Article: 7.5] [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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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: 0] [Impact Index Per Article: 0] [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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The dialysis facility levels and sizes are associated with outcomes of incident hemodialysis patients. Sci Rep 2021; 11:20560. [PMID: 34663846 PMCID: PMC8523705 DOI: 10.1038/s41598-021-00177-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 09/28/2021] [Indexed: 11/08/2022] Open
Abstract
The outcomes of patients with incident kidney failure who start hemodialysis are influenced by several factors. Whether hemodialysis facility characteristics are associated with patient outcomes is unclear. We included adults diagnosed as having kidney failure requiring hemodialysis during January 1, 2001 to December 31, 2013 from the Taiwan National Health Insurance Research Database to perform this retrospective cohort study. The exposures included different sizes and levels of hemodialysis facilities. The outcomes were all-cause mortality, cardiovascular death, infection-related death, hospitalization, and kidney transplantation. During 2001-2013, we identified 74,406 patients and divided them in to three groups according to the facilities where they receive hemodialysis: medical center (n = 8263), non-center hospital (n = 40,008), and clinic (n = 26,135). The multivariable Cox model demonstrated that a larger facility size was associated with a low mortality risk (hazard ratio [HR] 0.991, 95% confidence interval [95% CI] 0.984-0.998; every 20 beds per facility). Compared with medical centers, patients in non-center hospitals and clinics had higher mortality risks (HR 1.13, 95% CI 1.09-1.17 and HR 1.11, 95% CI 1.06-1.15, respectively). Patients in medical centers and non-center hospitals had higher risk of hospitalization (subdistribution HR [SHR] 1.11, 95% CI 1.10-1.12 and SHR 1.22, 95% CI 1.21-1.23, respectively). Patients in medical centers had the highest rate of kidney transplantation among the three groups. In patients with incident kidney failure, a larger hemodialysis facility size was associated with lower mortality. Overall, medical center patients had a lower mortality rate and higher transplantation rate, whereas clinic patients had a lower hospitalization risk.
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11
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Hallet J, Davis L, Mahar A, Mavros M, Beyfuss K, Liu Y, Law CHL, Earle C, Coburn N. Benefits of High-Volume Medical Oncology Care for Noncurable Pancreatic Adenocarcinoma: A Population-Based Analysis. J Natl Compr Canc Netw 2021; 18:297-303. [PMID: 32135510 DOI: 10.6004/jnccn.2019.7361] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 09/13/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Although pancreatic adenocarcinoma (PA) surgery performed by high-volume (HV) providers yields better outcomes, volume-outcome relationships are unknown for medical oncologists. This study examined variation in practice and outcomes in noncurative management of PA based on medical oncology provider volume. METHODS This population-based cohort study linked administrative healthcare datasets and included nonresected PA from 2005 through 2016. The volume of PA consultations per medical oncology provider per year was divided into quintiles, with HV providers (≥16 patients/year) constituting the fifth quintile and low-volume (LV) providers the first to fourth quintiles. Outcomes were receipt of chemotherapy and overall survival (OS). The Brown-Forsythe-Levene (BFL) test for equality of variances was performed to assess outcome variability between provider-volume quintiles. Multivariate regression models were used to examine the association between management by HV provider and outcomes. RESULTS A total of 7,062 patients with noncurable PA consulted with medical oncology providers. Variability was seen in receipt of chemotherapy and median survival based on provider volume (BFL, P<.001 for both), with superior 1-year OS for HV providers (30.1%; 95% CI, 27.7%-32.4%) compared with LV providers (19.7%; 95% CI, 18.5%-20.6%) (P<.001). After adjustment for age at diagnosis, sex, comorbidity burden, rural residence, income, and diagnosis period, HV provider care was independently associated with higher odds of receiving chemotherapy (odds ratio, 1.19; 95% CI, 1.05-1.34) and with superior OS (hazard ratio, 0.79; 95% CI, 0.74-0.84). CONCLUSIONS Significant variation was seen in noncurative management and outcomes of PA based on provider volume, with management by an HV provider being independently associated with superior OS and higher odds of receiving chemotherapy. This information is important to inform disease care pathways and care organization. Cancer care systems could consider increasing the number of HV providers to reduce variation and improve outcomes.
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Affiliation(s)
- Julie Hallet
- Odette Cancer Centre, Sunnybrook Health Sciences Centre.,University of Toronto.,Sunnybrook Research Institute.,Institute of Clinical Evaluative Sciences, Toronto, Ontario; and
| | | | - Alyson Mahar
- University of Manitoba, Winnipeg, Manitoba, Canada
| | | | | | - Ying Liu
- Institute of Clinical Evaluative Sciences, Toronto, Ontario; and
| | - Calvin H L Law
- Odette Cancer Centre, Sunnybrook Health Sciences Centre.,University of Toronto.,Sunnybrook Research Institute
| | - Craig Earle
- Odette Cancer Centre, Sunnybrook Health Sciences Centre.,Sunnybrook Research Institute.,Institute of Clinical Evaluative Sciences, Toronto, Ontario; and
| | - Natalie Coburn
- Odette Cancer Centre, Sunnybrook Health Sciences Centre.,University of Toronto.,Sunnybrook Research Institute.,Institute of Clinical Evaluative Sciences, Toronto, Ontario; and
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12
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Shinde RS, Pandrowala S, Navalgund S, Pai E, Bhandare MS, Chaudhari VA, Sullivan R, Shrikhande SV. Centralisation of Pancreatoduodenectomy in India: Where Do We Stand? World J Surg 2021; 44:2367-2376. [PMID: 32161986 DOI: 10.1007/s00268-020-05466-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The volume-outcome relationship dictates that high-volume centres lead to improved patient outcomes after pancreatoduodenectomy (PD). We conducted a retrospective review to fathom the situation in India for PD and whether referral to high-volume centres would make a positive impact. METHOD A systematic literature search in MEDLINE was performed, and all articles published from Indian centres from 01.03.2008 to 30.11.2019 were scrutinised. Any series with less than 20 patients, case reports, abstracts, unpublished data and personal communications were excluded. RESULTS A total of 36 unique series including 6226 patients from 24 institutes across India were identified. Amongst the 24 institutes, 2 institutes reported less than 10 cases/year, 11 reported 10-25 cases/year and 11 reported ≥26 cases/year. Overall perioperative morbidity was 42.4%, 43.4% and 41% for centres doing <10, 10-25 and ≥26 cases/year, respectively. Operative mortality also improved with increasing number of cases/year (5.1% vs. 6.6% vs. 3.2%, respectively). CONCLUSION With increasing volume of cases per year, trend towards improved PD outcomes is observed. To optimise the use of healthcare facilities, it would be pragmatic to consider building an organised referral system for complex surgeries to deliver unsurpassed patient care with maximum utilisation of the available healthcare infrastructure.
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Affiliation(s)
- Rajesh S Shinde
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Division of Cancer Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, 400012, India
| | - Saneya Pandrowala
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Division of Cancer Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, 400012, India
| | - Sunil Navalgund
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Division of Cancer Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, 400012, India
| | - Esha Pai
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Division of Cancer Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, 400012, India
| | - Manish S Bhandare
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Division of Cancer Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, 400012, India
| | - Vikram A Chaudhari
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Division of Cancer Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, 400012, India
| | - Richard Sullivan
- Institute of Cancer Policy, King's College London, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Shailesh V Shrikhande
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Division of Cancer Surgery, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, 400012, India.
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13
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Sato N, Kimura T, Kenjo A, Kofunato Y, Okada R, Ishigame T, Watanabe J, Marubashi S. Early intra-abdominal infection following pancreaticoduodenectomy:associated factors and clinical impact on surgical outcome. Fukushima J Med Sci 2020; 66:124-132. [PMID: 32963204 PMCID: PMC7790468 DOI: 10.5387/fms.2020-11] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Early intra-abdominal infection (IAI) following pancreaticoduodenectomy (PD) is an initial event relating to morbidities caused by postoperative pancreatic fistula (POPF). The aims of this study were to determine factors associated with IAI, and to investigate its impact on postoperative outcome. Consecutive patients, 113 in total, who underwent PD at Fukushima Medical University Hospital between January 2012 and September 2017 were included in this retrospective study. IAI was defined by positive bacterial culture from intra-abdominal drainage fluid any time through postoperative day 3 (POD3). Logistic regression analysis was used to identify the relevant factors associated with IAI. The clinical impact of the POD3 infection indicators related to POPF were assessed by multivariate analysis. The incidence of IAI, POPF, and mortality were 36.1%, 36.1%, and 0%, respectively. Independent factors associated with IAI were preoperative biliary drainage (PBD) (OR = 2.91, CI = 1.16-7.33, p = 0.023) and soft pancreas (OR = 8.67, CI = 2.37-31.77, p = 0.001). Among infection markers on POD3, the significant factors for POPF were CRP (OR = 1.18, CI = 1.08-1.30, p < 0.001), IAI (OR = 7,37, CI = 2.53-21.5, p < 0.001), and drain amylase (OR = 1.00, CI = 1.00-1.01, p = 0.001). In conclusion, PBD, soft pancreas, and higher age were associated with IAI. IAI has a significantly negative impact on postoperative outcome.
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Affiliation(s)
- Naoya Sato
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Fukushima Medical University
| | - Takashi Kimura
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Fukushima Medical University
| | - Akira Kenjo
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Fukushima Medical University
| | - Yasuhide Kofunato
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Fukushima Medical University
| | - Ryo Okada
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Fukushima Medical University
| | - Teruhide Ishigame
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Fukushima Medical University
| | - Junichiro Watanabe
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Fukushima Medical University
| | - Shigeru Marubashi
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Fukushima Medical University
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14
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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: 3.8] [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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15
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Grossberg AJ, Chu LC, Deig CR, Fishman EK, Hwang WL, Maitra A, Marks DL, Mehta A, Nabavizadeh N, Simeone DM, Weekes CD, Thomas CR. Multidisciplinary standards of care and recent progress in pancreatic ductal adenocarcinoma. CA Cancer J Clin 2020; 70:375-403. [PMID: 32683683 PMCID: PMC7722002 DOI: 10.3322/caac.21626] [Citation(s) in RCA: 241] [Impact Index Per Article: 60.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 05/21/2020] [Accepted: 05/26/2020] [Indexed: 12/12/2022] Open
Abstract
Despite tremendous gains in the molecular understanding of exocrine pancreatic cancer, the prognosis for this disease remains very poor, largely because of delayed disease detection and limited effectiveness of systemic therapies. Both incidence rates and mortality rates for pancreatic cancer have increased during the past decade, in contrast to most other solid tumor types. Recent improvements in multimodality care have substantially improved overall survival, local control, and metastasis-free survival for patients who have localized tumors that are amenable to surgical resection. The widening gap in prognosis between patients with resectable and unresectable or metastatic disease reinforces the importance of detecting pancreatic cancer sooner to improve outcomes. Furthermore, the developing use of therapies that target tumor-specific molecular vulnerabilities may offer improved disease control for patients with advanced disease. Finally, the substantial morbidity associated with pancreatic cancer, including wasting, fatigue, and pain, remains an under-addressed component of this disease, which powerfully affects quality of life and limits tolerance to aggressive therapies. In this article, the authors review the current multidisciplinary standards of care in pancreatic cancer with a focus on emerging concepts in pancreatic cancer detection, precision therapy, and survivorship.
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Affiliation(s)
- Aaron J. Grossberg
- Department of Radiation Medicine, Oregon Health & Science University, Portland, OR
- Brenden-Colson Center for Pancreatic Care, Oregon Health & Science University, Portland, OR
- Cancer Early Detection Advanced Research Center, Oregon Health & Science University, Portland, OR
| | - Linda C. Chu
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Christopher R. Deig
- Department of Radiation Medicine, Oregon Health & Science University, Portland, OR
| | - Eliot K. Fishman
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD
| | - William L. Hwang
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA
- Broad Institute of Harvard and MIT, Cambridge, MA
| | - Anirban Maitra
- Departments of Pathology and Translational Molecular Pathology, Sheikh Ahmed Pancreatic Cancer Research Center, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Daniel L. Marks
- Brenden-Colson Center for Pancreatic Care, Oregon Health & Science University, Portland, OR
- Department of Pediatrics and Pape Family Pediatric Research Institute, Oregon Health & Science University, Portland, OR
| | - Arnav Mehta
- Broad Institute of Harvard and MIT, Cambridge, MA
- Dana Farber Cancer Institute, Boston, MA
| | - Nima Nabavizadeh
- Department of Radiation Medicine, Oregon Health & Science University, Portland, OR
| | - Diane M. Simeone
- Departments of Surgery and Pathology, Perlmutter Cancer Center, NYU Langone Health, New York, NY
| | - Colin D. Weekes
- Division of Hematology/Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Charles R. Thomas
- Department of Radiation Medicine, Oregon Health & Science University, Portland, OR
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16
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Should all pancreatic surgery be centralized regardless of patients' comorbidity? HPB (Oxford) 2020; 22:1057-1066. [PMID: 31784212 DOI: 10.1016/j.hpb.2019.10.2443] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 10/27/2019] [Accepted: 10/29/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND It remains to be established whether centralization to high volume centers is essential for all patients undergoing pancreatic surgery. The aims of this study were to identify the optimal cut-off volume to optimize patient outcomes and to determine if patient comorbidity affected the volume-outcome relationship. METHODS Patients undergoing pancreatectomy from 2012 to 2015 were retrospectively identified (n = 12 333) in the French nationwide database. The 90-day Post-Operative Mortality (POM) was analyzed according to hospital volume of pancreatectomy (very low:<10, Low:10-19, High:20-49 and very high:≥50 resections/year) and Charlson Comorbidity Index (ChCI). RESULTS The overall POM was 6.9%. The cut-off of 20 pancreatic resections per year was identified as predictor of POM. Compared to high volume centers, POM was significantly higher in low and very low volume centers whatever the ChCl. Regarding surgical procedures, there was a significant decrease in POM with increasing hospital volume only after pancreaticoduodenectomy regardless of the ChCl. On multivariable analysis, low and very low volume centers were independently associated with increased mortality rates. CONCLUSION The optimal cut-off of annual caseload was 20 pancreatic resections. POM following pancreaticoduodenectomy is high in low and very low volume centers independently of ChCl, suggesting that this procedure should be centralized.
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17
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Theodorou CM, Anderson JE, Brenner M, Scalea TM, Inaba K, Cannon J, Seamon M, Spalding MC, Fox CJ, Moore EE, DuBose JJ, Galante JM. Practice, Practice, Practice! Effect of Resuscitative Endovascular Balloon Occlusion of the Aorta Volume on Outcomes: Data From the AAST AORTA Registry. J Surg Res 2020; 253:18-25. [PMID: 32311580 DOI: 10.1016/j.jss.2020.03.027] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 03/11/2020] [Accepted: 03/13/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an endovascular adjunct to hemorrhage control. Success relies on institutional support and focused training in arterial access. We hypothesized that hospitals with higher REBOA volumes will be more successful than low-volume hospitals at aortic occlusion with REBOA. METHODS This is a retrospective study from the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery Registry from November 2013 to January 2018. Patients aged ≥18 y who underwent REBOA were included. Successful placement of REBOA catheters (defined as hemodynamic improvement with balloon inflation) was compared between high-volume (≥80 cases; two hospitals), mid-volume (10-20 cases; four hospitals), and low-volume (<10 cases; 14 hospitals) hospitals, adjusting for patient factors. RESULTS Of 271 patients from 20 hospitals, 210 patients (77.5%) had successful REBOA placement. Most patients were male (76.0%) and sustained blunt trauma (78.1%). cardiopulmonary resuscitation (CPR) was ongoing at the time of REBOA placement in 34.5% of patients. Inpatient mortality was 67.4%, unchanged by hospital volume. Multivariable logistic regression found increased odds of successful REBOA placement at high-volume versus low-volume hospitals (odds ratio [OR], 7.50; 95% confidence interval [CI], 2.10-27.29; P = 0.002) and mid-volume versus low-volume hospitals (OR, 7.82; 95% CI, 1.52-40.31; P = 0.014) and decreased odds among patients undergoing CPR during REBOA placement (OR, 0.10; 95% CI, 0.03-0.34; P < 0.001) when adjusting for age, sex, mechanism of injury, prehospital CPR, CPR on admission, transfer status, hospital location of REBOA placement, Glasgow Coma Scale ≤ 13, and injury severity. CONCLUSIONS Hospitals with higher REBOA volumes were more likely to achieve hemodynamic improvement with REBOA inflation. However, mortality and complication rates were unchanged. Independent of hospital volume, ongoing CPR is associated with a decreased odds of successful REBOA placement.
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Affiliation(s)
- Christina M Theodorou
- Division of Trauma, University of California Davis Medical Center, Acute Care, and General Surgery Sacramento, CA.
| | - Jamie E Anderson
- Division of Trauma, University of California Davis Medical Center, Acute Care, and General Surgery Sacramento, CA
| | - Megan Brenner
- Department of Surgery, University of California Riverside School of Medicine Riverside, CA
| | - Thomas M Scalea
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Kenji Inaba
- Division of Surgical Critical Care and Trauma, Los Angeles County + University of Southern California Hospital, Los Angeles, CA
| | - Jeremy Cannon
- Division of Traumatology, University of Pennsylvania, Surgical Critical Care & Emergency Surgery, Philadelphia, PA
| | - Mark Seamon
- Division of Traumatology, University of Pennsylvania, Surgical Critical Care & Emergency Surgery, Philadelphia, PA
| | - M Chance Spalding
- Division of Trauma and Acute Care Surgery, Grant Medical Center, Columbus, OH
| | - Charles J Fox
- Department of Surgery, Denver Health Medical Center, Denver, CO
| | - Ernest E Moore
- Department of Surgery, Denver Health Medical Center, Denver, CO
| | - Joseph J DuBose
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Joseph M Galante
- Division of Trauma, University of California Davis Medical Center, Acute Care, and General Surgery Sacramento, CA
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18
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Hirpara DH, Gupta V, Davis LE, Zhao H, Hallet J, Mahar AL, Sutradhar R, Doherty M, Louie AV, Kidane B, Darling G, Coburn NG. Severe symptoms persist for Up to one year after diagnosis of stage I-III lung cancer: An analysis of province-wide patient reported outcomes. Lung Cancer 2020; 142:80-89. [PMID: 32120228 DOI: 10.1016/j.lungcan.2020.02.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 02/18/2020] [Accepted: 02/21/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Lung cancer is associated with significant disease- and treatment-related morbidity. The Edmonton Symptom Assessment System (ESAS) is a tool developed to elicit patients' own assessment of the severity of common cancer-associated symptoms. The objective of this study was to examine symptom severity in the 12 months following diagnosis of lung cancer, and to identify predictors of high symptom burden. MATERIALS AND METHODS This was a retrospective population-based cohort study, including patients with stage I-III lung cancer diagnosed between 2007-2016, and who had symptom screening in the 12 months following diagnosis. The proportion of patients reporting severe symptoms (ESAS ≥ 7) in the year following diagnosis was plotted over time. Multivariable regression models were constructed to identify factors associated with severe symptoms. RESULTS 69,440 unique symptom assessments were reported by 11,075 lung cancer patients. Tiredness was the most prevalent severe symptom (47.3 %), followed by shortness of breath (39.4 %) and poor wellbeing (36.5 %) among all disease stages. Patients diagnosed with higher stage disease reported more severe symptoms, but symptom trajectories were similar for all stages in the year following diagnosis. Disease stage (RR 1.10-2.01), comorbidity burden (RR 1.17-1.51), degree of socioeconomic marginalization (RR1.15-1.45), and female sex (RR 1.15-1.50) were associated with reporting severe symptoms in the year following diagnosis. CONCLUSION Severe physical and psychological symptoms persist throughout the first year following lung cancer diagnosis, regardless of disease stage. Those at risk of experiencing high symptom burden may benefit from targeted supportive care interventions, including psychosocial support aimed at improving health-related quality of life.
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Affiliation(s)
- Dhruvin H Hirpara
- Department of Surgery, University of Toronto, 149 College St., Toronto, ON M5T 1P5, Canada
| | - Vaibhav Gupta
- Department of Surgery, University of Toronto, 149 College St., Toronto, ON M5T 1P5, Canada
| | - Laura E Davis
- Sunnybrook Research Institute, 2075 Bayview Ave., Toronto, ON M4N 3M5, Canada
| | - Haoyu Zhao
- ICES, 2075 Bayview Ave., Toronto, ON M4N 3M5, Canada
| | - Julie Hallet
- Department of Surgery, University of Toronto, 149 College St., Toronto, ON M5T 1P5, Canada; Sunnybrook Research Institute, 2075 Bayview Ave., Toronto, ON M4N 3M5, Canada; ICES, 2075 Bayview Ave., Toronto, ON M4N 3M5, Canada
| | - Alyson L Mahar
- Manitoba Centre for Health Policy, University of Manitoba, 727 McDermot Ave., Winnipeg, MB R3B 3P5, Canada
| | - Rinku Sutradhar
- Sunnybrook Research Institute, 2075 Bayview Ave., Toronto, ON M4N 3M5, Canada; ICES, 2075 Bayview Ave., Toronto, ON M4N 3M5, Canada
| | - Mark Doherty
- Division of Medical Oncology, University of Toronto, 200 Elizabeth St., Toronto, ON M5G 2C4, Canada
| | - Alexander V Louie
- Division of Radiation Oncology, University of Toronto, 200 Elizabeth St., Toronto, ON M5G 2C4, Canada
| | - Biniam Kidane
- Section of Thoracic Surgery, University of Manitoba, 820 Sherbrook St., Winnipeg, MB R3A 1R9, Canada
| | - Gail Darling
- Division of Thoracic Surgery, Toronto General Hospital, 200 Elizabeth St., Toronto, ON M5G 2C4, Canada
| | - Natalie G Coburn
- Department of Surgery, University of Toronto, 149 College St., Toronto, ON M5T 1P5, Canada; Sunnybrook Research Institute, 2075 Bayview Ave., Toronto, ON M4N 3M5, Canada; ICES, 2075 Bayview Ave., Toronto, ON M4N 3M5, Canada.
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19
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Warschkow R, Tsai C, Köhn N, Erdem S, Schmied B, Nussbaum DP, Gloor B, Müller SA, Blazer D, Worni M. Role of lymphadenectomy, adjuvant chemotherapy, and treatment at high-volume centers in patients with resected pancreatic cancer-a distinct view on lymph node yield. Langenbecks Arch Surg 2020; 405:43-54. [PMID: 32040705 DOI: 10.1007/s00423-020-01859-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 01/27/2020] [Indexed: 12/22/2022]
Abstract
PURPOSE While the importance of lymphadenectomy is well-established for patients with resectable pancreatic cancer, its direct impact on survival in relation to other predictive factors is still ill-defined. METHODS The National Cancer Data Base 2006-2015 was queried for patients with resected pancreatic adenocarcinoma (stage IA-IIB). Patients were dichotomized into the following two groups, those with 1-14 resected lymph nodes and those with ≥ 15. Optimal number of resected lymph nodes and the effect of lymphadenectomy on survival were assessed using various statistical modeling techniques. Mediation analysis was performed to differentiate the direct and indirect effect of lymph node resection on survival. RESULTS A total of 21,912 patients were included; median age was 66 years (IQR 59-73), 48.9% were female. Median number of resected lymph nodes was 15 (IQR 10-22), 10,163 (46.4%) had 1-14 and 11,749 (53.6%) had ≥ 15 lymph nodes retrieved. Lymph node positivity increased by 4.1% per lymph node up to eight examined lymph nodes, and by 0.6% per lymph node above eight. Five-year overall survival was 17.9%. Overall survival was better in the ≥ 15 lymph node group (adjusted HR 0.91, CI 0.88-0.95, p < 0.001). On a continuous scale, survival improved with increasing LNs collected. Patients who underwent adjuvant chemotherapy and were treated at high-volume centers had improved overall survival compared with their counterparts (adjusted HR 0.59, CI 0.57-0.62, p < 0.001; adjusted HR 0.86, CI 0.83-0.89, p < 0.001, respectively). Mediation analysis revealed that lymphadenectomy had only 18% direct effect on improved overall survival, while 82% of its effect were mediated by other factors like treatment at high-volume hospitals and adjuvant chemotherapy. DISCUSSION While higher number of resected lymph nodes increases lymph node positivity and is associated with better overall survival, most of the observed survival benefit is mediated by chemotherapy and treatment at high-volume centers.
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Affiliation(s)
- Rene Warschkow
- Department of Surgery, Kantonsspital St. Gallen, Gallen, Switzerland
| | - Catherine Tsai
- Department of Visceral Surgery and Medicine, Inselspital, Bern, Switzerland
| | - Nastassja Köhn
- Department of Visceral Surgery and Medicine, Inselspital, Bern, Switzerland
| | - Suna Erdem
- Department of Visceral Surgery and Medicine, Inselspital, Bern, Switzerland
| | - Bruno Schmied
- Department of Surgery, Kantonsspital St. Gallen, Gallen, Switzerland
| | - Daniel P Nussbaum
- Berner Viszeralchirurgie, Klinik Beau-Site, Hirslanden, Bern, Switzerland
| | - Beat Gloor
- Department of Visceral Surgery and Medicine, Inselspital, Bern, Switzerland
| | - Sascha A Müller
- Berner Viszeralchirurgie, Klinik Beau-Site, Hirslanden, Bern, Switzerland
| | - Dan Blazer
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Mathias Worni
- Department of Surgery, Duke University Medical Center, Durham, NC, USA. .,Swiss Institute for Translational and Entrepreneurial Medicine, Stiftung Lindenhof, Campus SLB, Bern, Switzerland. .,Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, CH-4058, Basel, Switzerland.
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20
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Nakata K, Yamamoto H, Miyata H, Kakeji Y, Seto Y, Yamaue H, Yamamoto M, Nakamura M. Definition of the objective threshold of pancreatoduodenectomy with nationwide data systems. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 27:107-113. [PMID: 31876378 DOI: 10.1002/jhbp.704] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND This study aimed to define an objective evidence-based threshold of high-volume hospitals (HVHs) for pancreatoduodenectomy (PD) using nationwide data systems. METHODS A total of 36,453 patients underwent PD in 1,499 hospitals from 2012 to 2015 were collected from the National Clinical Database in Japan. Restricted cubic spline model with risk adjustment was used for definition of an objective evidence-based threshold of HVHs. RESULTS The restricted cubic spline curve of 30-day and in-hospital mortality showed a continuous decrease with an increase in hospital volume and plateau phase of mortality was detected between approximately 30 and 50 PDs/year. On the basis of this curve, we defined hospitals ≥30 PDs/year as HVHs and ≤29 PDs/year as non-HVHs. We also sub-classified hospitals <5, 5-29, 30-49, and ≥50 PDs/year as low-volume, intermediate-volume, high-volume, and very high-volume hospitals using the spline curve. The odds ratio (OR) of risk-adjusted mortality decreased as hospital volume increased, with an OR of 0.34 for HVHs and 0.26 for very HVHs compared with low-volume hospitals. CONCLUSIONS We consider that this concept is applicable to other high-risk procedures for reducing mortality after these procedures, which could improve medical care and health services.
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Affiliation(s)
- Kohei Nakata
- Japanese Society of Hepato-Biliary-Pancreatic Surgery, Tokyo, Japan
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Fukuoka, 812-8582, Japan
| | - Hiroyuki Yamamoto
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroaki Miyata
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoshihiro Kakeji
- Database Committee, The Japanese Society of Gastroenterological Surgery, Tokyo, Japan
| | - Yasuyuki Seto
- The Japanese Society of Gastroenterological Surgery, Tokyo, Japan
| | - Hiroki Yamaue
- Japanese Society of Hepato-Biliary-Pancreatic Surgery, Tokyo, Japan
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Masakazu Yamamoto
- Japanese Society of Hepato-Biliary-Pancreatic Surgery, Tokyo, Japan
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Masafumi Nakamura
- Japanese Society of Hepato-Biliary-Pancreatic Surgery, Tokyo, Japan
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Fukuoka, 812-8582, Japan
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21
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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: 7.0] [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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22
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Bubis LD, Davis LE, Canaj H, Gupta V, Jeong Y, Barbera L, Li Q, Moody L, Karanicolas PJ, Sutradhar R, Coburn NG, Mahar AL. Patient-Reported Symptom Severity Among 22,650 Cancer Outpatients in the Last Six Months of Life. J Pain Symptom Manage 2020; 59:58-66.e4. [PMID: 31430522 DOI: 10.1016/j.jpainsymman.2019.08.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 08/09/2019] [Accepted: 08/09/2019] [Indexed: 12/17/2022]
Abstract
CONTEXT Understanding the magnitude and risk factors for symptom burden of patients with cancer at the end of life is critical to guiding effective patient- and system-level interventions. OBJECTIVES We aimed to estimate the prevalence of severe patient-reported symptoms among cancer outpatients during the six months before death and to identify patient groups at a higher risk for reporting severe symptoms. METHODS This was a retrospective cohort study of cancer decedents at regional cancer centers from 2010 to 2016. Patient-reported Edmonton Symptom Assessment System (ESAS) scores from the last six months of life were linked to administrative databases. The proportion of patients reporting severe symptom scores (≥7) for anxiety, depression, drowsiness, lack of appetite, nausea, pain, shortness of breath, tiredness, and overall well-being during the six months before death was described. Multivariable modified Poisson regression analyses were used to identify risk factors for reporting severe symptom scores. RESULTS Of 39,084 cancer decedents, 22,650 had one or more symptom assessments recorded in the last six months of life, resulting in 92,757 ESAS assessments. Severe scores were highest for tiredness (56%), lack of appetite (46%), and impaired well-being (45%). The proportion of patients reporting severe symptom scores was stable before progressively increasing at three months before death. Elderly, women, patients with high comorbidity, immigrants, and living in urban areas or with high material deprivation were at increased risk of reporting severe scores. CONCLUSIONS Despite an integrated symptom screening program, rates of severe patient-reported symptom scores before death were high for outpatients with cancer. Patient subgroups at increased risk of severe symptom burden may benefit from targeted interventions. Ongoing review of routinely collected symptom data may be used to assess the supportive care needs and guide targeted interventions at the health-system level.
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Affiliation(s)
- Lev D Bubis
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Laura E Davis
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Hera Canaj
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Vaibhav Gupta
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Yunni Jeong
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Lisa Barbera
- Division of Radiation Oncology, University of Calgary, Calgary, Canada
| | - Qing Li
- Institute for Clinical Evaluative Sciences, Toronto, Canada
| | | | - Paul J Karanicolas
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Rinku Sutradhar
- Institute for Clinical Evaluative Sciences, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; Department of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Natalie G Coburn
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Canada.
| | - Alyson L Mahar
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
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23
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Maggino L, Liu JB, Thompson VM, Pitt HA, Ko CY, Vollmer CM. Assessing the influence of experience in pancreatic surgery: a risk-adjusted analysis using the American College of Surgeons NSQIP database. HPB (Oxford) 2019; 21:1773-1783. [PMID: 31153836 DOI: 10.1016/j.hpb.2019.04.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 03/07/2019] [Accepted: 04/22/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The association between higher surgical volume and better perioperative outcomes after pancreatectomy has been extensively demonstrated. However, how different notions of experience impact outcomes of surgeons operating within high-quality scenarios remains unclear. METHODS Self-reported experience parameters from ACS-NSQIP HPB-Collaborative surgeons were merged with 2014-2016 ACS-NSQIP clinical data. The association of various experience parameters with outcomes was investigated through uni- and multivariable analyses. Hierarchical regression assessed surgeon performance. RESULTS 111/151 HPB-Collaborative surgeons provided responses (73.5%). Compared to the other 532 ACS-NSQIP surgeons performing pancreatectomy, HPB-Collaborative surgeons performed 7692/16,239 of the overall pancreatectomies (47.3%), with improved outcomes of serious morbidity, pancreatic fistula, reoperation, duration of stay and readmissions. Median age of respondents was 49 years and 92.8% were fellowship-trained. Median career and annual pancreatectomy volume were 400 and 35, respectively; median annual institutional volume was 100 resections. On unadjusted analyses, several aspects of experience were associated with the outcomes studied, especially for pancreatoduodenectomy; however, none remained significant after multivariable adjustment. Surgeons' profiling showed substantial homogeneity in performance for both pancreatoduodenectomy and distal pancreatectomy. CONCLUSIONS Contemporary data shows that for surgeons operating in high quality settings clinical outcomes are largely independent of indicators of greater experience.
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Affiliation(s)
- Laura Maggino
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Unit of General and Pancreatic Surgery, Department of Surgery and Oncology, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Jason B Liu
- American College of Surgeons, Chicago, IL, USA; Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | | | - Henry A Pitt
- Department of Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | | | - Charles M Vollmer
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
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24
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Comparison of Patient-Reported Outcomes in Laparoscopic and Open Right Hemicolectomy: A Retrospective Cohort Study. Dis Colon Rectum 2019; 62:1439-1447. [PMID: 31567922 DOI: 10.1097/dcr.0000000000001485] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Open and laparoscopic resections for colon cancer have equivalent perioperative morbidity and mortality. However, there are little data concerning patient-reported outcomes in the early postdischarge period. OBJECTIVE We examined patient-reported outcomes in the early postdischarge period for open and laparoscopic right hemicolectomy for colon cancer. DESIGN This was a retrospective cohort study. SETTINGS The study was conducted using linked administrative healthcare databases in the province of Ontario, Canada. PATIENTS Patients undergoing laparoscopic or open right hemicolectomy for colon cancer between January 2010 and December 2014 were identified using the Ontario Cancer Registry and physician billing data. MAIN OUTCOME MEASURES The primary outcome was the presence of moderate-to-severe symptom scores on the Edmonton Symptom Assessment System (≥4 of 10) within 6 weeks of hospital discharge after right hemicolectomy. RESULTS A total of 1022 patients completed ≥1 Edmonton Symptom Assessment System survey within 6 weeks of surgery and were included in the study. Patients undergoing laparoscopic resection were more likely to have an urban residence, to have undergone planned resections, and to have had proportionally more stage 1 disease compared with patients undergoing open resection. On multivariable analyses, adjusting for patient demographics, cancer stage, and planned versus unplanned admission status, there were no differences in the adjusted odds of moderate-to-severe symptom scores between the laparoscopic and open approaches. LIMITATIONS Edmonton Symptom Assessment System scores are not collected for inpatients and thus only represent outpatient postoperative visits. Scores were reported by 19% of all resections in the population, with a bias to patients treated at cancer centers, and therefore they are not fully representative of the general population of right hemicolectomy. The Edmonton Symptom Assessment System is not a disease-specific tool and may not measure all relevant outcomes for patients undergoing right hemicolectomy. CONCLUSIONS Receipt of the open or laparoscopic surgical technique was not associated with increased risk of elevated symptom burden in the early postdischarge period. See Video Abstract at http://links.lww.com/DCR/B27. REPORTE COMPARATIVO DE RESULTADOS INFORMADOS DE PACIENTES CON HEMICOLECTOMÍA DERECHA LAPAROSCÓPICA Y ABIERTA: UN ESTUDIO DE COHORTE RETROSPECTIVO: Las resecciones abiertas y laparoscópicas para el cáncer de colon, presentan semejante morbilidad y mortalidad perioperatoria. Sin embargo, en el período inicial posterior al alta, hay pocos datos sobre los resultados informados por los pacientes.Examinamos los resultados informados por los pacientes, en el período temprano posterior al alta, para hemicolectomía derecha abierta y laparoscópica en cáncer de colon.Estudio de cohorte retrospectivo.El estudio se realizó utilizando bases de datos administrativas de atención médica en la provincia de Ontario, Canadá.Pacientes sometidos a hemicolectomía derecha abierta o laparoscópica para cáncer de colon, de enero 2010 a diciembre 2014, se identificaron mediante el Registro de cáncer de Ontario y de los datos médicos de facturación.El resultado primario, después de la hemicolectomía derecha, fue la presencia de síntomas de moderados a graves en el Sistema de evaluación de síntomas de Edmonton (≥4 de cada 10) dentro de las seis semanas posteriores al alta hospitalaria.Un total de 1022 pacientes completaron al menos una encuesta del Sistema de evaluación de síntomas de Edmonton, dentro de las seis semanas de la cirugía y se incluyeron en el estudio. Los pacientes sometidos a resección laparoscópica fueron más propensos a residir en zona urbana, a resecciones planificadas y proporcionalmente más enfermedad en estadio 1; en comparación con los pacientes sometidos a resecciones abiertas. En los análisis multivariables, que se ajustaron a la demografía del paciente, al estadio del cáncer y del estado de ingreso planificado versus no planificado, no hubo diferencias en las probabilidades ajustadas de las puntuaciones de los síntomas moderados a severos entre el abordaje abierto o laparoscópico.Las puntuaciones del Sistema de evaluación de síntomas de Edmonton no se recopilan para pacientes hospitalizados y por lo tanto, solo representan las visitas postoperatorias de pacientes ambulatorios. Las puntuaciones informadas fueron del 19% de todas las resecciones en la población, con un sesgo en los pacientes tratados en los Centros de Cáncer y por lo tanto, no son totalmente representativos de la población general de hemicolectomía derecha. El Sistema de evaluación de síntomas de Edmonton no es una herramienta específica de la enfermedad y puede no medir todos los resultados relevantes para los pacientes que se someten a una hemicolectomía derecha.La recepción entre una técnica quirúrgica abierta o laparoscópica, no se asoció con un aumento del riesgo de síntomas en el período temprano posterior al alta. Vea el Resumen del Video en http://links.lww.com/DCR/B27.
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25
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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: 32] [Impact Index Per Article: 6.4] [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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26
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Kleive D, Sahakyan MA, Labori KJ, Lassen K. Nasogastric Tube on Demand is Rarely Necessary After Pancreatoduodenectomy Within an Enhanced Recovery Pathway. World J Surg 2019; 43:2616-2622. [PMID: 31161355 DOI: 10.1007/s00268-019-05045-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Evidence-based guidelines for enhanced recovery (ERAS) pathways after pancreatoduodenectomy (PD) are available. Routine use of nasogatric tube (NGT) after PD is not recommended. This study aims to evaluate the need for NGT reinsertion after PD performed within an ERAS setting. METHODS It is a prospective observational study of all patients undergoing PD in a tertiary referral hospital within the study period from 2015 throughout 2016. Pre- and postoperative variables were collected. Patients requiring NGT reinsertion were identified. Comparative analysis of patients with and without a NGT reinsertion was performed, as well as multivariate analysis for risk factors for on-demand NGT reinsertion. RESULTS Two-hundred and one patients were included. In total, 45 (22.4%) patients required NGT reinsertion after PD. A total of 32 (15.9%) patients underwent a relaparotomy. Reinsertion of NGT in patients not undergoing a relaparotomy occurred in 26 (15.4%) patients. The presence of a major postoperative complication was a risk factor for reinsertion of NGT, OR 5.27 (2.54-10.94, p = 0.001). Patients with the need for a NGT reinsertion had a higher frequency of major postoperative complications and relaparotomy compared to patients without the need of a NGT reinsertion, 26 (57.8%) versus 32 (20.5%), p < 0.001 and 19 (42.2%) versus 13 (8.3%), p < 0.001, respectively. CONCLUSION Routine use of NGT after PD is not justified within an ERAS setting. Immediate removal of the NGT after the procedure can be performed safely, and reinsertion on demand is rarely necessary in uncomplicated courses.
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Affiliation(s)
- D Kleive
- Department of Hepato-Pancreato-Biliary Surgery, Rikshospitalet, Oslo University Hospital, Oslo, Norway.
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Mushegh A Sahakyan
- Department of Surgery N1, Yerevan State Medical University After M. Heratsi, Yerevan, Armenia
| | - K J Labori
- Department of Hepato-Pancreato-Biliary Surgery, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - K Lassen
- Department of Hepato-Pancreato-Biliary Surgery, Rikshospitalet, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, The Arctic University of Norway, Tromsø, Norway
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27
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Mehtsun WT, Hashimoto DA, Ferrone CR. Status of 5-Year Survivors of the Whipple Procedure for Pancreatic Adenocarcinoma. Adv Surg 2019; 53:253-269. [PMID: 31327451 DOI: 10.1016/j.yasu.2019.04.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Winta T Mehtsun
- Department of Surgery, Massachusetts General Hospital, 15 Parkman Street, WAC 460, Boston, MA 02114, USA
| | - Daniel A Hashimoto
- Department of Surgery, Massachusetts General Hospital, 15 Parkman Street, WAC 460, Boston, MA 02114, USA
| | - Cristina R Ferrone
- Department of Surgery, Massachusetts General Hospital, 15 Parkman Street, WAC 460, Boston, MA 02114, USA.
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28
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Montgomery JR, Sung RS, Woodside KJ. Transplant Center Volume: Is Bigger Better? Am J Kidney Dis 2019; 74:432-434. [PMID: 31358310 DOI: 10.1053/j.ajkd.2019.04.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Accepted: 04/25/2019] [Indexed: 11/11/2022]
Affiliation(s)
| | - Randall S Sung
- Department of Surgery, University of Michigan, Ann Arbor, MI
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29
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Association Between Travel Distance, Hospital Volume, and Outcomes Following Resection of Cholangiocarcinoma. J Gastrointest Surg 2019; 23:944-952. [PMID: 30815777 DOI: 10.1007/s11605-019-04162-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 02/05/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND The objective of the current study was to characterize the association between travel distance/hospital volume relative to outcomes following resection of cholangiocarcinoma. METHODS Patients were identified using the 2004-2015 National Cancer Database and stratified into quartiles according to travel distance/hospital volume. Multivariable regression models were utilized to examine the impact of travel distance and hospital volume on quality-of-care metrics and overall survival. RESULTS Among 5125 patients, the majority of patients had T1/2 (N = 2006, 41.1%) and N0 disease (N = 2498, 50.9%). Median hospital quartile surgical volumes in cases/year were low volume (LV) 6, intermediate low volume (ILV) 7, intermediate high volume (IHV) 12, and high volume (HV) 24 cases/year. Median travel distance quartiles in miles were short travel (ST) 2.7, intermediate short travel (IST) 7.9, intermediate long travel (ILT) 18.9, and long travel (LT) 84.7. Longer travel distances were associated with better overall survival, as every 10 miles was associated with a 2% decrease in mortality (p = 0.02). Differences in quality-of-care metrics were largely mediated through travel distance. CONCLUSIONS Travel distance and hospital volume were associated with certain quality-of-care metrics among patients with cholangiocarcinoma. After controlling for hospital volume and travel distance simultaneously, only travel distance was associated with decreased risk of mortality.
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30
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Mahar AL, Davis LE, Bubis LD, Li Q, Sutradhar R, Coburn NG, Barbera L. Factors associated with receipt of symptom screening in the year after cancer diagnosis in a universal health care system: a retrospective cohort study. ACTA ACUST UNITED AC 2019; 26:e8-e16. [PMID: 30853804 DOI: 10.3747/co.26.4160] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Purpose Patient-reported symptom data are collected prospectively by a provincial cancer agency to mitigate the significant symptom burden that patients with cancer experience. However, an assessment of whether such symptom screening occurs uniformly for those patients has yet to be performed. In the present study, we investigated patient, disease, and health system factors associated with receipt of symptom screening in the year after a cancer diagnosis. Methods Patients diagnosed with cancer between 2007 and 2014 were identified. We measured whether 1 or more symptom screenings were recorded in the year after diagnosis. A multivariable modified Poisson regression with robust error variance was used to identify predictors [age, comorbidity, rurality, socioeconomic status, immigration status, cancer site, registration at a regional cancer centre (cc), and year of diagnosis] of being screened for symptoms. Results Of 425,905 patients diagnosed with cancer, 163,610 (38%) had 1 or more symptom screening records in the year after diagnosis, and 75% survived at least 1 year. We identified variability in symptom screening by primary cancer site, regional cc, age, sex, comorbidity, material deprivation, rurality of residence, and immigration status. Patients who had been diagnosed with melanoma or endocrine cancers, who were not registered at a regional cc, who lived in the most urban areas, who were elderly, and who were immigrants were least likely to undergo symptom screening after diagnosis. Conclusions Our evaluation of the implementation of a population-based symptom screening program in a universal health care system identified populations who are at risk for not receiving screening and who are therefore future targets for improvements in population symptom screening and better management of cancer-related symptoms at diagnosis.
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Affiliation(s)
- A L Mahar
- Department of Community Health Sciences, University of Manitoba, Winnipeg, MB
| | - L E Davis
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, ON
| | - L D Bubis
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON.,Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON
| | | | - R Sutradhar
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, ON.,Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON.,ICES, Toronto, ON
| | - N G Coburn
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, ON.,Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON.,Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON.,ICES, Toronto, ON.,Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, ON
| | - L Barbera
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, ON.,ICES, Toronto, ON.,Department of Radiation Oncology, University of Toronto, Toronto, ON
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31
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Liu XM, Li Y, Xiang JX, Ma F, Lu Q, Guo YG, Yan XP, Wang B, Zhang XF, Lv Y. Magnetic compression anastomosis for biliojejunostomy and pancreaticojejunostomy in Whipple's procedure: An initial clinical study. J Gastroenterol Hepatol 2019; 34:589-594. [PMID: 30278106 DOI: 10.1111/jgh.14500] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 09/12/2018] [Accepted: 09/25/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Magnetic anastomosis has been attempted in biliary and intestinal reconstruction. The objective of the current study was to introduce an initial clinical use of magnetic compression anastomosis for pancreaticojejunostomy and biliojejunostomy in Whipple's procedure. METHODS Patients with peri-ampullary carcinoma and dilated bile and pancreatic ducts were prospectively enrolled from 2016 to 2017. After pancreaticoduodenectomy, an appropriate mother magnet and drainage tube was placed in the proximal bile duct and pancreatic duct. The daughter magnets were introduced to mate with the mother magnets at the anastomotic sites. A close postoperative surveillance and routine cholangiopancreaticography via the drainage tube were performed. RESULTS One female and three male patients with a median age of 69 years (range, 57-77) were included. The diameter of the common bile ducts and pancreatic ducts ranged from 8 to 15 mm, and 7 to 10 mm, respectively. The median time duration for biliojejunostomy and pancreaticojejunostomy was 7 (range, 5-8 min) min and 9 (range, 8-10 min) min, respectively. The median time of biliojejunostomy and pancreaticojejunostomy formation was 17 (range, 15-21 days) days and 11 (range, 10-18 days), respectively. With a median follow up of 313 days, one patient developed biliary anastomotic stricture at 11 months after surgery, and underwent stent placement via percutaneous transhepatic drainage sinus, and recovered well. CONCLUSIONS Magnetic anastomosis is safe, effective, and simple for both biliojejunostomy and pancreaticojejunostomy in Whipple's procedure.
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Affiliation(s)
- Xue-Min Liu
- Department of Hepatobiliary Surgery and Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Shaanxi Provincial Regenerative Medicine and Surgical Engineering Research Center, Xi'an, China
| | - Yu Li
- Department of Hepatobiliary Surgery and Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Shaanxi Provincial Regenerative Medicine and Surgical Engineering Research Center, Xi'an, China
| | - Jun-Xi Xiang
- Department of Hepatobiliary Surgery and Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Shaanxi Provincial Regenerative Medicine and Surgical Engineering Research Center, Xi'an, China
| | - Feng Ma
- Department of Hepatobiliary Surgery and Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Shaanxi Provincial Regenerative Medicine and Surgical Engineering Research Center, Xi'an, China
| | - Qiang Lu
- Department of Hepatobiliary Surgery and Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Shaanxi Provincial Regenerative Medicine and Surgical Engineering Research Center, Xi'an, China
| | - Yan-Guang Guo
- Department of Hepatobiliary Surgery and Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Shaanxi Provincial Regenerative Medicine and Surgical Engineering Research Center, Xi'an, China
| | - Xiao-Peng Yan
- Department of Hepatobiliary Surgery and Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Shaanxi Provincial Regenerative Medicine and Surgical Engineering Research Center, Xi'an, China
| | - Bo Wang
- Department of Hepatobiliary Surgery and Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Shaanxi Provincial Regenerative Medicine and Surgical Engineering Research Center, Xi'an, China
| | - Xu-Feng Zhang
- Department of Hepatobiliary Surgery and Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Shaanxi Provincial Regenerative Medicine and Surgical Engineering Research Center, Xi'an, China
| | - Yi Lv
- Department of Hepatobiliary Surgery and Institute of Advanced Surgical Technology and Engineering, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Shaanxi Provincial Regenerative Medicine and Surgical Engineering Research Center, Xi'an, China
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Perrotta de Souza LM, Moreira JP, Fogaça HS, Eulálio JMR, Luiz RR, de Souza HS. Increasing pancreatic cancer is not paralleled by pancreaticoduodenectomy volumes in Brazil: A time trend analysis. Hepatobiliary Pancreat Dis Int 2019; 18:79-86. [PMID: 30583855 DOI: 10.1016/j.hbpd.2018.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 12/04/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Currently, surgical resection represents the only curative treatment for pancreatic cancer (PC), however, the majority of tumors are no longer resectable by the time of diagnosis. The aim of this study was to describe time trends and distribution of pancreaticoduodenectomies (PDs) performed for treating PC in Brazil in recent years. METHODS Data were retrospectively obtained from Brazilian Health Public System (namely DATASUS) regarding hospitalizations for PC and PD in Brazil from January 2008 to December 2015. PC and PD rates and their mortalities were estimated from DATASUS hospitalizations and analyzed for age, gender and demographic characteristics. RESULTS A total of 2364 PDs were retrieved. Albeit PC incidence more than doubled, the number of PDs increased only 37%. Most PDs were performed in men (52.2%) and patients between 50 and 69 years old (59.5%). Patients not surgically treated and those 70 years or older had the highest in-hospital mortality rates. The most developed regions (Southeast and South) as well as large metropolitan integrated municipalities registered 76.2% and 54.8% of the procedures, respectively. LMIM PD mortality fluctuated, ranging from 13.6% in 2008 to 11.8% in 2015. CONCLUSIONS This study suggests a trend towards regionalization and volume-outcome relationships for PD due to PC, as large metropolitan integrated municipalities registered most of the PDs and more stable mortality rates. The substantial differences between PD and PC increasing rates reveals a limiting step on the health system resoluteness. Reduction in the number of hospital beds and late access to hospitalization, despite improvement in diagnostic methods, could at least in part explain these findings.
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Affiliation(s)
- Lucila M Perrotta de Souza
- Department of Internal Medicine, School of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Jessica Pl Moreira
- Institute of Public Health Studies (IESC), Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Homero S Fogaça
- Department of Internal Medicine, School of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - José Marcus Raso Eulálio
- Department of Surgery, School of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Ronir R Luiz
- Institute of Public Health Studies (IESC), Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Heitor Sp de Souza
- Department of Internal Medicine, School of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; D'Or Institute for Research and Education, Rio de Janeiro, Brazil.
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Latchana N, Davis L, Coburn NG, Mahar A, Liu Y, Hammad A, Kagedan D, Elmi M, Siddiqui M, Earle CC, Hallet J. Population-based study of the impact of surgical and adjuvant therapy at the same or a different institution on survival of patients with pancreatic adenocarcinoma. BJS Open 2018; 3:85-94. [PMID: 30734019 PMCID: PMC6354229 DOI: 10.1002/bjs5.50115] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Accepted: 09/18/2018] [Indexed: 12/21/2022] Open
Abstract
Background Pancreatic cancer surgery is increasingly regionalized in high‐volume centres. Provision of adjuvant chemotherapy in the same institution can place a burden on patients, whereas receiving adjuvant chemotherapy at a different institution closer to home may create disparities in care. This study compared long‐term outcomes of patients with pancreatic adenocarcinoma receiving adjuvant chemotherapy at the institution where they had undergone surgery with outcomes for those receiving chemotherapy at a different institution. Methods This was a population‐based study of patients receiving adjuvant chemotherapy after resection of pancreatic adenocarcinoma performed at ten designated hepatopancreatobiliary centres in Ontario, Canada, between 2004 and 2014. Patients were divided into those receiving chemotherapy at the same institution as surgery or a different institution from where surgery was performed. The primary outcome was overall survival (OS). Multivariable Cox regression assessed the association between OS and each chemotherapy group, adjusted for potential confounders. Results Of 589 patients, 374 (63·5 per cent) received adjuvant chemotherapy at the same institution as surgery. After adjusting for age, sex, co‐morbidity, socioeconomic status, rural living, tumour stage, margin positivity and year of surgery, the location of adjuvant chemotherapy was not independently associated with OS (hazard ratio 1·03, 95 per cent c.i. 0·85 to 1·24). For patients who underwent chemotherapy at a different institution, mean travel distance to receive chemotherapy was less (22·9 km) than that needed for surgery (106·7 km). Conclusion After pancreatectomy for pancreatic adenocarcinoma at specialized hepatopancreatobiliary surgery centres, OS was not affected by the location of the centre delivering adjuvant chemotherapy. Receiving this treatment in a local centre reduced patients' travel burden.
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Affiliation(s)
- N Latchana
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Odette Cancer Centre - Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - L Davis
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - N G Coburn
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Odette Cancer Centre - Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada.,Institute of Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - A Mahar
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Y Liu
- Institute of Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - A Hammad
- Sunnybrook Research Institute, Toronto, Ontario, Canada.,Department of General Surgery, Mansoura University, Mansoura, Egypt
| | - D Kagedan
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - M Elmi
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - M Siddiqui
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - C C Earle
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Institute of Clinical Evaluative Sciences, Toronto, Ontario, Canada.,Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - J Hallet
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of General Surgery, Odette Cancer Centre - Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Toronto, Ontario, Canada.,Institute of Clinical Evaluative Sciences, Toronto, Ontario, Canada
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34
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Kagedan DJ, Mosko JD, Dixon ME, Karanicolas PJ, Wei AC, Goyert N, Li Q, Mittmann N, Coburn NG. Changes in preoperative endoscopic and percutaneous bile drainage in patients with periampullary cancer undergoing pancreaticoduodenectomy in Ontario: effect on clinical practice of a randomized trial. ACTA ACUST UNITED AC 2018; 25:e430-e435. [PMID: 30464694 DOI: 10.3747/co.25.4007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background In 2010, a multicentre randomized controlled trial reported increased postoperative complications in pancreaticoduodenectomy (pde) patients undergoing preoperative biliary decompression (pbd). We evaluated the effect of that publication on rates of pbd at the population level. Methods This retrospective observational cohort study identified patients undergoing pde for malignancy, 2005-2013, linking them with administrative health care databases covering medical services for a population of 13.5 million. Patients undergoing pbd within 6 weeks before their surgery were identified using physician billing codes and were divided into those undergoing pde before and after article publication, with a 6-month washout period. Chi-square tests were used to compare rates of pbd. Results Of 1997 pde patients identified, 963 underwent surgery before article publication, and 911, after (123 during the washout period). The rate of pbd was 47.5% before publication, and 41.6% after (p = 0.01). The lowest pbd rates occurred immediately after publication, in 2010 and 2011. Similar results were observed when the cohort was restricted to patients seen preoperatively by a gastroenterologist (n = 1412). Conclusions Rates of pbd have declined a small, but significant, amount after randomized trial publication. Persistence of pbd might relate to suboptimal knowledge translation, the role of pbd in diagnosis of periampullary malignancy, and treatment of complications (cholangitis, severe hyperbilirubinemia) or anticipation of delay from diagnosis to surgery. The nadir in pbd rates after article publication and the subsequent rise suggest an element of transience in the effect of article publication on clinical practice. Further investigation into the reasons for persistent pbd is needed.
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Affiliation(s)
- D J Kagedan
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON
| | - J D Mosko
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, ON.,Faculty of Medicine, University of Toronto, Toronto, ON
| | - M E Dixon
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON
| | - P J Karanicolas
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON.,Faculty of Medicine, University of Toronto, Toronto, ON.,Sunnybrook Health Sciences Centre, Toronto, ON
| | - A C Wei
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON.,Faculty of Medicine, University of Toronto, Toronto, ON.,Institute of Health Policy, Management, and Evaluation, Toronto, ON.,Princess Margaret Cancer Centre, University Health Network, Toronto, ON
| | - N Goyert
- Sunnybrook Health Sciences Centre, Toronto, ON
| | - Q Li
- Institute for Clinical Evaluative Sciences, Toronto, ON
| | - N Mittmann
- Health Outcomes and PharmacoEconomic Research Centre, Toronto, ON
| | - N G Coburn
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON.,Faculty of Medicine, University of Toronto, Toronto, ON.,Sunnybrook Health Sciences Centre, Toronto, ON.,Institute of Health Policy, Management, and Evaluation, Toronto, ON
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Abstract
Despite the identification of more active systemic therapy combinations for pancreatic cancer, cures remain elusive and feasible only in patients with localized, operable disease. When examining outcome data from phase III adjuvant trials conducted during the past decade, the survival for patients with localized disease has improved, likely owing to a combination of factors including more active adjuvant therapy and improved surgical and perioperative care. Perhaps the greatest recent change in the care of patients with localized pancreatic cancer has been the extension of surgery to tumors previously thought to be inoperable because of involvement of major blood vessels. These so-called "borderline resectable pancreatic cancers" have now been objectively defined, and their management is being studied in randomized trials. This has been made feasible by the availability of more active systemic therapy combinations that are increasingly being used in the neoadjuvant setting. Given the increasing activity of systemic regimens, the challenges in delivering such therapy in the postoperative setting, and the numerous novel agents in late stages of clinical development, it is reasonable to hypothesize that the neoadjuvant setting may eventually become the standard of care for patients with resectable disease.
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Bubis LD, Davis L, Mahar A, Barbera L, Li Q, Moody L, Karanicolas P, Sutradhar R, Coburn NG. Symptom Burden in the First Year After Cancer Diagnosis: An Analysis of Patient-Reported Outcomes. J Clin Oncol 2018; 36:1103-1111. [DOI: 10.1200/jco.2017.76.0876] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Purpose Improvement in the quality of life of patients with cancer requires attention to symptom burden across the continuum of care, with the use of patient-reported outcomes key to achieving optimal care. Yet there have been few studies that have examined symptoms in the early postdiagnosis period during which suboptimal symptom control may be common. A comprehensive analysis of temporal trends and risk factors for symptom burden in newly diagnosed patients with cancer is essential to guide supportive care strategies. Methods A retrospective observational study was performed of patients who were diagnosed with cancer between January 2007 and December 2014 and who survived at least 1 year. Patient-reported Edmonton Symptom Assessment System scores, which are prospectively collected at outpatient visits, were linked to provincial administrative health care data. We described the proportion of patients who reported moderate-to-severe symptom scores by month during the first year after diagnosis according to disease site. Multivariable logistic regression models were constructed to identify risk factors for moderate-to-severe symptom scores. Results Of 120,745 patients, 729,861 symptom assessments were recorded within 12 months of diagnosis. For most symptoms, odds of elevated scores were highest in the first month, whereas nausea had increased odds of elevated scores up to 6 months after diagnosis. On multivariable analysis, cancer site, younger age, higher comorbidity, female sex, lower income, and urban residence were associated with significantly higher odds of elevated symptom burden. Conclusion A high prevalence of moderate-to-severe symptom scores was observed in cancers of all sites. Patients are at risk of experiencing multiple symptoms in the immediate postdiagnosis period, which underscores the need to address supportive care requirements early in the cancer journey. Patient subgroups who are at higher risk of experiencing moderate-to-severe symptoms should be targeted for tailored supportive care interventions.
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Affiliation(s)
- Lev D. Bubis
- Lev D. Bubis, Lisa Barbera, Lesley Moody, Paul Karanicolas, Rinku Sutradhar, and Natalie G. Coburn, University of Toronto; Laura Davis, Alyson Mahar, Paul Karanicolas, and Natalie G. Coburn, Sunnybrook Health Sciences Centre; Lisa Barbera, Qing Li, and Rinku Sutradhar and Natalie G. Coburn, Institute for Clinical Evaluative Sciences; Lisa Barbera and Lesley Moody, Cancer Care Ontario, Toronto, Ontario, Canada
| | - Laura Davis
- Lev D. Bubis, Lisa Barbera, Lesley Moody, Paul Karanicolas, Rinku Sutradhar, and Natalie G. Coburn, University of Toronto; Laura Davis, Alyson Mahar, Paul Karanicolas, and Natalie G. Coburn, Sunnybrook Health Sciences Centre; Lisa Barbera, Qing Li, and Rinku Sutradhar and Natalie G. Coburn, Institute for Clinical Evaluative Sciences; Lisa Barbera and Lesley Moody, Cancer Care Ontario, Toronto, Ontario, Canada
| | - Alyson Mahar
- Lev D. Bubis, Lisa Barbera, Lesley Moody, Paul Karanicolas, Rinku Sutradhar, and Natalie G. Coburn, University of Toronto; Laura Davis, Alyson Mahar, Paul Karanicolas, and Natalie G. Coburn, Sunnybrook Health Sciences Centre; Lisa Barbera, Qing Li, and Rinku Sutradhar and Natalie G. Coburn, Institute for Clinical Evaluative Sciences; Lisa Barbera and Lesley Moody, Cancer Care Ontario, Toronto, Ontario, Canada
| | - Lisa Barbera
- Lev D. Bubis, Lisa Barbera, Lesley Moody, Paul Karanicolas, Rinku Sutradhar, and Natalie G. Coburn, University of Toronto; Laura Davis, Alyson Mahar, Paul Karanicolas, and Natalie G. Coburn, Sunnybrook Health Sciences Centre; Lisa Barbera, Qing Li, and Rinku Sutradhar and Natalie G. Coburn, Institute for Clinical Evaluative Sciences; Lisa Barbera and Lesley Moody, Cancer Care Ontario, Toronto, Ontario, Canada
| | - Qing Li
- Lev D. Bubis, Lisa Barbera, Lesley Moody, Paul Karanicolas, Rinku Sutradhar, and Natalie G. Coburn, University of Toronto; Laura Davis, Alyson Mahar, Paul Karanicolas, and Natalie G. Coburn, Sunnybrook Health Sciences Centre; Lisa Barbera, Qing Li, and Rinku Sutradhar and Natalie G. Coburn, Institute for Clinical Evaluative Sciences; Lisa Barbera and Lesley Moody, Cancer Care Ontario, Toronto, Ontario, Canada
| | - Lesley Moody
- Lev D. Bubis, Lisa Barbera, Lesley Moody, Paul Karanicolas, Rinku Sutradhar, and Natalie G. Coburn, University of Toronto; Laura Davis, Alyson Mahar, Paul Karanicolas, and Natalie G. Coburn, Sunnybrook Health Sciences Centre; Lisa Barbera, Qing Li, and Rinku Sutradhar and Natalie G. Coburn, Institute for Clinical Evaluative Sciences; Lisa Barbera and Lesley Moody, Cancer Care Ontario, Toronto, Ontario, Canada
| | - Paul Karanicolas
- Lev D. Bubis, Lisa Barbera, Lesley Moody, Paul Karanicolas, Rinku Sutradhar, and Natalie G. Coburn, University of Toronto; Laura Davis, Alyson Mahar, Paul Karanicolas, and Natalie G. Coburn, Sunnybrook Health Sciences Centre; Lisa Barbera, Qing Li, and Rinku Sutradhar and Natalie G. Coburn, Institute for Clinical Evaluative Sciences; Lisa Barbera and Lesley Moody, Cancer Care Ontario, Toronto, Ontario, Canada
| | - Rinku Sutradhar
- Lev D. Bubis, Lisa Barbera, Lesley Moody, Paul Karanicolas, Rinku Sutradhar, and Natalie G. Coburn, University of Toronto; Laura Davis, Alyson Mahar, Paul Karanicolas, and Natalie G. Coburn, Sunnybrook Health Sciences Centre; Lisa Barbera, Qing Li, and Rinku Sutradhar and Natalie G. Coburn, Institute for Clinical Evaluative Sciences; Lisa Barbera and Lesley Moody, Cancer Care Ontario, Toronto, Ontario, Canada
| | - Natalie G. Coburn
- Lev D. Bubis, Lisa Barbera, Lesley Moody, Paul Karanicolas, Rinku Sutradhar, and Natalie G. Coburn, University of Toronto; Laura Davis, Alyson Mahar, Paul Karanicolas, and Natalie G. Coburn, Sunnybrook Health Sciences Centre; Lisa Barbera, Qing Li, and Rinku Sutradhar and Natalie G. Coburn, Institute for Clinical Evaluative Sciences; Lisa Barbera and Lesley Moody, Cancer Care Ontario, Toronto, Ontario, Canada
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Bouquot M, Gaujoux S, Cauchy F, Birnbaum D, Dokmak S, Levy P, Soubrane O, Sauvanet A. Pancreatectomy for pancreatic incidentaloma: What are the risks? Pancreatology 2018; 18:114-121. [PMID: 29146108 DOI: 10.1016/j.pan.2017.11.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 11/05/2017] [Accepted: 11/06/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Pancreatic incidentalomas (PI) are nowadays common but the benefit-risk balance of surgery remains difficult to determine. METHODS Monocentric retrospective study of 881 pancreatectomies comparing resected PI with symptomatic lesion. Univariate and multivariate (MV) analyses were done to identify risk factors of malignancy in PI undergoing surgery. RESULTS Overall, 32% of pancreatectomies were performed for PI. Median size of PI was 30 mm (vs 28 mm; p = 0.15) and 49% were cystic (vs 42%; p = 0.197). Resected PI were mostly located in distal pancreas (61% vs 34%; p < 0.001), less frequently malignant (49% vs 59%; p = 0.004). PNETs were more frequent in PI (50% vs 21%; p < 0.001). Distal pancreatectomy (36% vs 23%; p < 0.001) or parenchyma-sparing surgery (34% vs 13%; p < 0.001) were more frequently performed for PI. Overall mortality (1.1% vs 1.2%) and morbidity (70% vs 68%) were not significantly different between both groups. Severe morbidity was lower for PI (15% vs 22%; p = 0.007). In multivariate analysis, age>55 years (HR 6.14; p < 0.001), size >20 mm (HR:26.7; p < 0.001) and biliary dilatation (HR 29.9; p = 0.027) were independent risk factors of malignancy and, when associated, the likelihood of malignancy was above 90%. CONCLUSIONS PI represent about 30% of indications for pancreatectomy and when resected after careful selection are malignant in 50% of cases.
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Affiliation(s)
- Morgane Bouquot
- AP-HP, Hôpital Beaujon, Department of Hepato-Pancreato-Biliary Surgery - DHU Unity, Clichy, 92110, France
| | - Sébastien Gaujoux
- AP-HP, Hôpital Beaujon, Department of Hepato-Pancreato-Biliary Surgery - DHU Unity, Clichy, 92110, France; University Paris Descartes, Paris, France
| | - François Cauchy
- AP-HP, Hôpital Beaujon, Department of Hepato-Pancreato-Biliary Surgery - DHU Unity, Clichy, 92110, France; University Paris Diderot, Paris, France
| | - David Birnbaum
- AP-HP, Hôpital Beaujon, Department of Hepato-Pancreato-Biliary Surgery - DHU Unity, Clichy, 92110, France; University Paris Diderot, Paris, France
| | - Safi Dokmak
- AP-HP, Hôpital Beaujon, Department of Hepato-Pancreato-Biliary Surgery - DHU Unity, Clichy, 92110, France; University Paris Diderot, Paris, France
| | - Philippe Levy
- University Paris Diderot, Paris, France; AP-HP, Hôpital Beaujon, Department of Pancreatology- DHU Unity, Clichy, 92110, France
| | - Olivier Soubrane
- AP-HP, Hôpital Beaujon, Department of Hepato-Pancreato-Biliary Surgery - DHU Unity, Clichy, 92110, France; University Paris Diderot, Paris, France
| | - Alain Sauvanet
- AP-HP, Hôpital Beaujon, Department of Hepato-Pancreato-Biliary Surgery - DHU Unity, Clichy, 92110, France; University Paris Diderot, Paris, France.
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Endo I, Kumamoto T, Matsuyama R. Postoperative complications and mortality: Are they unavoidable? Ann Gastroenterol Surg 2017; 1:160-163. [PMID: 29863116 DOI: 10.1002/ags3.12045] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Itaru Endo
- Department of Gastroenterological Surgery Graduate School of Medicine Yokohama City University Yokohama Japan
| | - Takafumi Kumamoto
- Department of Gastroenterological Surgery Graduate School of Medicine Yokohama City University Yokohama Japan
| | - Ryusei Matsuyama
- Department of Gastroenterological Surgery Graduate School of Medicine Yokohama City University Yokohama Japan
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Abstract
OPINION STATEMENT Pancreatic cancer surgery is a continuously evolving field. Despite tremendous advances in perioperative outcomes, pancreatic resection is still associated with substantial morbidity, and mortality is not nil. Institutional caseload is a well-established determinant of patient outcomes, and centralization to experienced centers is essential to the safety and oncological appropriateness of the resection. Minimally invasive approaches are increasingly applied for pancreatic resection, even in cancer patients. Nevertheless, the level of evidence in this field remains low. Minimally invasive distal pancreatectomy appears potentially beneficial towards some perioperative outcomes, although its oncological results remain incompletely studied. Data regarding perioperative and oncologic outcomes for minimally invasive pancreaticoduodenectomy (Whipple's resection) is even less mature, but suggest that similar results as the open approach can be achieved in selected, high-volume centers. Conversely, its indiscriminate adoption by inexperienced surgeons and institutions has potential deleterious effects given its steep learning curve. Newer neoadjuvant treatment protocols display enhanced ability to downstage advanced tumors, increasing candidates for potentially curative surgery. Conversely, putative benefits of neoadjuvant treatment in patients with technically resectable tumors have not been reliably demonstrated and its optimal indications remain highly controversial.
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Affiliation(s)
- Laura Maggino
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, USA.,Unit of General and Pancreatic Surgery, Department of Surgery and Oncology-The Pancreas Institute, University of Verona Hospital Trust, Verona, Italy
| | - Charles M Vollmer
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, USA.
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