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Henry AC, Salaheddine Y, Holster JJ, Daamen LA, Bruno MJ, Derksen WJM, van Driel LMJW, van Eijck CH, van Lienden KP, Molenaar IQ, van Santvoort HC, Vleggaar FP, Groot Koerkamp B, Verdonk RC. Late cholangitis after pancreatoduodenectomy: A common complication with or without anatomical biliary obstruction. Surgery 2024:S0039-6060(24)00467-7. [PMID: 39054185 DOI: 10.1016/j.surg.2024.06.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 06/10/2024] [Accepted: 06/30/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND Postoperative cholangitis is a common complication after pancreatoduodenectomy that can occur with or without anatomical biliary obstruction. This study aimed to investigate the incidence, diagnosis, treatment, and risk factors of cholangitis after pancreatoduodenectomy. METHODS We performed a retrospective cohort study of consecutive patients who underwent pancreatoduodenectomy in 2 Dutch tertiary pancreatic centers (2010-2019). Primary outcome was postoperative cholangitis, defined as systemic inflammation with abnormal liver tests without another focus of infection, at least 1 month after resection. Diagnostic and therapeutic strategies were evaluated. Two types of postoperative cholangitis were distinguished; obstructive cholangitis (benign stenosis of the hepaticojejunostomy) and nonobstructive cholangitis. Potential risk factors were identified using logistic regression analysis. RESULTS Postoperative cholangitis occurred in 93 of 900 patients (10.3%). Median time to first episode of cholangitis was 8 months (interquartile range 4-16) after pancreatoduodenectomy. Multiple episodes of cholangitis occurred in 44 patients (47.3%) and readmission was necessary in 83 patients (89.2%). No cholangitis-related mortality was observed. Obstructive cholangitis was seen in 37 patients (39.8%) and nonobstructive cholangitis in 56 patients (60.2%). Surgery was performed for cholangitis in 7 patients (7.5%) and consisted of revision of the hepaticojejunostomy or elongation of the biliary limb. Postoperative biliary leakage (odds ratio 2.56; 95% confidence interval 1.42-4.62; P = .0018) was independently associated with postoperative cholangitis. CONCLUSION Postoperative cholangitis unrelated to cancer recurrence was seen in 10% of patients after pancreatoduodenectomy. Nonobstructive cholangitis was more common than obstructive cholangitis. Postoperative biliary leakage was an independent risk factor.
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Affiliation(s)
- Anne Claire Henry
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Youcef Salaheddine
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jessica J Holster
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Lois A Daamen
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marco J Bruno
- Department of Gastroenterology & Hepatology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Wouter J M Derksen
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lydi M J W van Driel
- Department of Gastroenterology & Hepatology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Krijn P van Lienden
- Department of Radiology, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein, University Medical Center Utrecht, Utrecht, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology & Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology & Hepatology, Regional Academic Cancer Center Utrecht, St. Antonius Hospital Nieuwegein, University Medical Center Utrecht, Utrecht, The Netherlands.
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2
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Hunger R, Kowalski C, Paasch C, Kirbach J, Mantke R. Outcome variation and the role of caseload in certified colorectal cancer centers - a retrospective cohort analysis of 90 000 cases. Int J Surg 2024; 110:3461-3469. [PMID: 38498361 PMCID: PMC11175722 DOI: 10.1097/js9.0000000000001285] [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] [Received: 08/02/2023] [Accepted: 02/22/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND Studies have shown that surgical treatment of colorectal carcinomas in certified centers leads to improved outcomes. However, there were considerable fluctuations in outcome parameters. It has not yet been examined whether this variability is due to continuous differences between hospitals or variability within a hospital over time. MATERIALS AND METHODS In this retrospective observational cohort study, administrative quality assurance data of 153 German-certified colorectal cancer centers between 2010 and 2019 were analyzed. Six outcome quality indicators (QIs) were studied: 30-day postoperative mortality (POM) rate, surgical site infection (SSI) rate, anastomotic insufficiency (AI) rate, and revision surgery (RS) rate. AI and RS were also analyzed for colon (C) and rectal cancer operations (R). Variability was analyzed by funnel plots with 95% and 99% control limits and modified Cleveland dot plots. RESULTS In the 153 centers, 90 082 patients with colon cancer and 47 623 patients with rectal cancer were treated. Average QI scores were 2.7% POM, 6.2% SSI, 4.8% AI-C, 8.5% AI-R, 9.1% RS-C, and 9.8% RS-R. The funnel plots revealed that for every QI, about 10.1% of hospitals lay above the upper 99% and about 8.7% below the lower 99% control limit. In POM, SSI, and AI-R, a significant negative correlation with the average annual caseload was observed. CONCLUSION The analysis showed high variability in outcome quality between and within the certified colorectal cancer centers. Only a small number of hospitals had a high performance on all six QIs, suggesting that significant quality variation exists even within the group of certified centers.
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Affiliation(s)
- Richard Hunger
- Department of General Surgery, University Hospital Brandenburg
| | | | | | - Jette Kirbach
- Department of General Surgery, University Hospital Brandenburg
| | - René Mantke
- Department of General Surgery, University Hospital Brandenburg
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Brandenburg
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Teles de Campos S, Diniz P, Castelo Ferreira F, Voiosu T, Arvanitakis M, Devière J. Assessing the impact of center volume on the cost-effectiveness of centralizing ERCP. Gastrointest Endosc 2024; 99:950-959.e4. [PMID: 38061478 DOI: 10.1016/j.gie.2023.11.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 11/03/2023] [Accepted: 11/21/2023] [Indexed: 05/20/2024]
Abstract
BACKGROUND AND AIMS ERCP is a complex endoscopic procedure in which the center's procedure volume influences outcomes. With the increasing healthcare expenses and limited resources, promoting cost-effective care becomes essential for healthcare provision. This study was a cost-effectiveness analysis to evaluate the hypothesis that high-volume (HV) centers perform ERCP with higher quality at lower costs than low-volume (LV) centers. METHODS A baseline case compared the current distribution of ERCPs among HV and LV centers with a hypothetical scenario in which all ERCPs are performed at HV centers. A cost-effectiveness analysis was constructed, followed by 1- and 2-way sensitivity analyses, and probabilistic sensitivity analysis using Monte Carlo simulations. RESULTS In the baseline case, the incremental cost-effectiveness ratio was -$151,270 per year, due to the hypothetical scenario's lower costs and slightly higher quality-adjusted life years. The model was most sensitive to changes in transportation costs (109.34%), probability of significant adverse events (AEs) after successful ERCP at LV centers (42.12%), utility after ERCP with significant AEs (30.10%), and probability of significant AEs after successful ERCP at HV centers (23.53%); only transportation costs above $3655 changed the study outcome, however. The current ERCP distribution would only be cost-effective if LV centers achieved higher success (≥92.4% vs 89.3%), with much lower significant AEs (≤.5% vs 6.7%). The study's main findings remained unchanged while combining all model parameters in the probabilistic sensitivity analysis. CONCLUSIONS Our findings show that HV centers have high-performance rates at lower costs, raising the need to consider the principle of centralization of ERCPs into HV centers to improve the quality of care.
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Affiliation(s)
- Sara Teles de Campos
- Gastroenterology Department, Digestive Unit, Champalimaud Foundation, Lisbon, Portugal; Université Libre Bruxelles, Brussels, Belgium; Department of Bioengineering and iBB, Institute for Bioengineering and Biosciences, Instituto Superior Técnico, Fondation Michel Cremer, Universidade de Lisboa, Lisbon, Portugal.
| | - Pedro Diniz
- Department of Bioengineering and iBB, Institute for Bioengineering and Biosciences, Instituto Superior Técnico, Fondation Michel Cremer, Universidade de Lisboa, Lisbon, Portugal; Associate Laboratory i4HB, Institute for Health and Bioeconomy, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal
| | - Frederico Castelo Ferreira
- Department of Bioengineering and iBB, Institute for Bioengineering and Biosciences, Instituto Superior Técnico, Fondation Michel Cremer, Universidade de Lisboa, Lisbon, Portugal; Associate Laboratory i4HB, Institute for Health and Bioeconomy, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal
| | - Theodor Voiosu
- Gastroenterology Department, Colentina Clinical Hospital, Carol Davila Faculty of Medicine, Bucharest, Romania
| | - Marianna Arvanitakis
- Université Libre Bruxelles, Brussels, Belgium; Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Brussels, Belgium
| | - Jacques Devière
- Gastroenterology Department, Digestive Unit, Champalimaud Foundation, Lisbon, Portugal; Université Libre Bruxelles, Brussels, Belgium; Department of Bioengineering and iBB, Institute for Bioengineering and Biosciences, Instituto Superior Técnico, Fondation Michel Cremer, Universidade de Lisboa, Lisbon, Portugal; Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Brussels, Belgium
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Liang JN, Anklowitz AJ, Livezey JB, O'Hara TA, Aranda MC, Bandera B. Practice Patterns of Pancreatic Surgery Within the Military. Am Surg 2024:31348241241746. [PMID: 38513255 DOI: 10.1177/00031348241241746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
INTRODUCTION Pancreatic surgery is technically challenging, with mortality rates at high-volume centers ranging from 0% to 5%. An inverse relationship between surgeon volume and perioperative mortality has been reported suggesting that patients benefit from experienced surgeons at high-volume centers. There is little published on the volume of pancreatic surgeries performed in military treatment facilities (MTF) and there is no centralization policy regarding pancreatic surgery. This study evaluates pancreatic procedures at MTFs. We hypothesize that a small group of MTFs perform most pancreatic procedures, including more complex pancreatic surgeries. METHODS This is a retrospective review of de-identified data from MHS Mart (M2) from 2014 to 2020. The database contains patient data from all Defense Health Agency treatment facilities. Variables collected include number and types of pancreatic procedures performed and patient demographics. The primary endpoint was the number and type of surgery for each MTF. RESULTS Twenty-six MTFs performed pancreatic surgeries from 2014 to 2020. There was a significant decrease in the number of cases from 2014 to 2020. Nine hospitals performed one surgery over eight years. The most common surgery was a distal pancreatectomy, followed by a pancreaticoduodenectomy. There was a decrease in the number of pancreaticoduodenectomies and distal pancreatectomies performed over this period. CONCLUSIONS Pancreatic surgery is being performed at few MTFs with a downward trajectory over time. Further studies would be needed to assess the impact on patient care regarding postoperative complications, barriers to timely patient care, and impact on readiness of military surgeons.
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Affiliation(s)
- Joy N Liang
- General Surgery Residency Program, Dwight D. Eisenhower Army Medical Center, Fort Eisenhower, GA, USA
| | - Andrew J Anklowitz
- General Surgery Residency Program, Dwight D. Eisenhower Army Medical Center, Fort Eisenhower, GA, USA
| | - Jonathan B Livezey
- General Surgery Residency Program, Dwight D. Eisenhower Army Medical Center, Fort Eisenhower, GA, USA
| | - Thomas A O'Hara
- General Surgery Residency Program, Dwight D. Eisenhower Army Medical Center, Fort Eisenhower, GA, USA
| | - Marcos C Aranda
- General Surgery Residency Program, Dwight D. Eisenhower Army Medical Center, Fort Eisenhower, GA, USA
| | - Bradley Bandera
- Reno School of Medicine, University of Nevada, Reno, NV, USA
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5
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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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Perri G, van Hilst J, Li S, Besselink MG, Hogg ME, Marchegiani G. Teaching modern pancreatic surgery: close relationship between centralization, innovation, and dissemination of care. BJS Open 2023; 7:zrad081. [PMID: 37698977 PMCID: PMC10496870 DOI: 10.1093/bjsopen/zrad081] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 07/19/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND Pancreatic surgery is increasingly moving towards centralization in high-volume centres, supported by evidence on the volume-outcome relationship. At the same time, minimally invasive pancreatic surgery is becoming more and more established worldwide, and interest in new techniques, such as robotic pancreatoduodenectomy, is growing. Such recent innovations are reshaping modern pancreatic surgery, but they also represent new challenges for surgical training in its current form. METHODS This narrative review presents a chosen selection of literature, giving a picture of the current state of training in pancreatic surgery, together with the authors' own views, and in the context of centralization and innovation towards minimally invasive techniques. RESULTS Centralization of pancreatic surgery at high-volume centres, volume-outcome relationships, innovation through minimally invasive technologies, learning curves in both traditional and minimally invasive surgery, and standardized training paths are the different, but deeply interconnected, topics of this article. Proper training is essential to ensure quality of care, but innovation and centralization may represent challenges to overcome with new training models. CONCLUSION Innovations in pancreatic surgery are introduced with the aim of increasing the quality of care. However, their successful implementation is deeply dependent on dissemination and standardization of surgical training, adapted to fit in the changing landscape of modern pancreatic surgery.
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Affiliation(s)
- Giampaolo Perri
- Department of General and Pancreatic Surgery, Verona University Hospital, Verona, Italy
| | - Jony van Hilst
- Department of Surgery, Amsterdam UMC, location VU, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Shen Li
- Department of Surgical Oncology, University of Chicago, Chicago, Illinois, USA
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, location VU, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Melissa E Hogg
- Department of HPB Surgery, NorthShore Health System, Evanston, Illinois, USA
| | - Giovanni Marchegiani
- Department of Surgical, Oncological and Gastroenterological Sciences (DiSCOG), University of Padua, Padua, Italy
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Fickenscher M, Vorontsov O, Müller T, Radeleff B, Graeb C. Pancreaticobiliary Diseases with Severe Complications as a Rare Indication for Emergency Pancreaticoduodenectomy: A Single-Center Experience and Review of the Literature. J Clin Med 2023; 12:5760. [PMID: 37685827 PMCID: PMC10488344 DOI: 10.3390/jcm12175760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/22/2023] [Accepted: 09/02/2023] [Indexed: 09/10/2023] Open
Abstract
The pancreaticobiliary system is a complex and vulnerable anatomic region. Small changes can lead to severe complications. Pancreaticobiliary disorders leading to severe complications include malignancies, pancreatitis, duodenal ulcer, duodenal diverticula, vascular malformations, and iatrogenic or traumatic injuries. Different therapeutic strategies, such as conservative, interventional (e.g., embolization, stent graft applications, or biliary interventions), or surgical therapy, are available in early disease stages. Therapeutic options in patients with severe complications such as duodenal perforation, acute bleeding, or sepsis are limited. If less invasive procedures are exhausted, an emergency pancreaticoduodenectomy (EPD) can be the only option left. The aim of this study was to analyze a single-center experience of EPD performed for benign non-trauma indications and to review the literature concerning EPD. Between January 2015 and January 2022, 11 patients received EPD due to benign non-trauma indications at our institution. Data were analyzed regarding sex, age, indication, operative parameters, length of hospital stay, postoperative morbidity, and mortality. Furthermore, we performed a literature survey using the PubMed database and reviewed reported cases of EPD. Eleven EPD cases due to benign non-trauma indications were analyzed. Indications included peptic duodenal ulcer with penetration into the hepatopancreatic duct and the pancreas, duodenal ulcer with acute uncontrollable bleeding, and penetration into the pancreas, and a massive perforated duodenal diverticulum with peritonitis and sepsis. The mean operative time was 369 min, and the median length of hospital stay was 35.8 days. Postoperative complications occurred in 4 out of 11 patients (36.4%). Total 90-day postoperative mortality was 9.1% (1 patient). We reviewed 17 studies and 22 case reports revealing 269 cases of EPD. Only 20 cases of EPD performed for benign non-trauma indications are reported in the literature. EPD performed for benign non-trauma indications remains a rare event, with only 31 reported cases. The data analysis of all available cases from the literature revealed an increased postoperative mortality rate of 25.8%. If less invasive approaches are exhausted, EPD is still a life-saving procedure with acceptable results. Performed by surgeons with a high level of experience in hepatobiliary and pancreatic surgery, mortality rates below 10% can be achieved.
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Affiliation(s)
- Maximilian Fickenscher
- Department of General-, Visceral- and Thoracic Surgery, Sana Hospital Hof, 95032 Hof, Germany
| | - Oleg Vorontsov
- Department of General-, Visceral- and Thoracic Surgery, Sana Hospital Hof, 95032 Hof, Germany
| | - Thomas Müller
- Department of Gastroenterology, Sana Hospital Hof, 95032 Hof, Germany
| | - Boris Radeleff
- Department of Diagnostic and Interventional Radiology, Sana Hospital Hof, 95032 Hof, Germany
| | - Christian Graeb
- Department of General-, Visceral- and Thoracic Surgery, Sana Hospital Hof, 95032 Hof, Germany
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8
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Tachezy M, Gebauer F, Yekebas E, Izbicki JR. Failure of a Multi-Centric Clinical Trial Investigating Neoadjuvant Radio-Chemotherapy in Resectable Pancreatic Carcinoma (NEOPA-NCT01900327)-Which Lessons Are Learnt? Cancers (Basel) 2023; 15:4262. [PMID: 37686537 PMCID: PMC10487154 DOI: 10.3390/cancers15174262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 07/28/2023] [Accepted: 07/31/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND A significant number of clinical trials must be prematurely discontinued due to recruitment failure, and only a small fraction publish results and a failure analysis. Based on our experience on conducting the NEOPA trial on neoadjuvant radiochemotherapy for resectable and borderline resectable pancreatic carcinoma (NCT01900327-funded by the German Federal Ministry of Education and Research-BMBF), we performed an analysis of potential reasons for recruitment failure and general problems in conducting clinical trials in Germany. METHODS Systematic analysis of environmental factors, trial history, conducting and funding in the background of the published literature. RESULTS The recruitment failure was based on various study-specific conceptional and local environmental aspects and in peculiarities of the German surgical study culture. General reservations against a neo-adjuvant study concept combined with game changing scientific progresses during the long-lasting planning and funding phase have led to a reduced interest in the trial design and recruitment. CONCLUSIONS Trial planning and conducting should be focused, professionalized and financed on a national basis. Individual interests must be subordinated to reach the goal to perform more relevant and successful clinical trials in Germany. Bureaucratic processes must be further fastened between a trial idea and the start of a study.
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Affiliation(s)
- Michael Tachezy
- Department of General, Visceral and Thoracic Surgery, University-Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany; (F.G.); (E.Y.); (J.R.I.)
| | - Florian Gebauer
- Department of General, Visceral and Thoracic Surgery, University-Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany; (F.G.); (E.Y.); (J.R.I.)
- Department of General and Visceral Surgery, HELIOS University Hospital Wuppertal, 42283 Wuppertal, Germany
| | - Emre Yekebas
- Department of General, Visceral and Thoracic Surgery, University-Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany; (F.G.); (E.Y.); (J.R.I.)
| | - Jakob Robert Izbicki
- Department of General, Visceral and Thoracic Surgery, University-Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany; (F.G.); (E.Y.); (J.R.I.)
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9
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Augustinus S, Schafrat PJM, Janssen BV, Bonsing BA, Brosens LAA, Busch OR, Crobach S, Doukas M, van Eijck CH, van der Geest LGM, Groot Koerkamp B, de Hingh IHJT, Raicu GM, van Santvoort HC, van Velthuysen ML, Verheij J, Besselink MG, Farina Sarasqueta A. Nationwide Impact of Centralization, Neoadjuvant Therapy, Minimally Invasive Surgery, and Standardized Pathology Reporting on R0 Resection and Overall Survival in Pancreatoduodenectomy for Pancreatic Cancer. Ann Surg Oncol 2023; 30:5051-5060. [PMID: 37210448 PMCID: PMC10319672 DOI: 10.1245/s10434-023-13465-9] [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: 11/10/2022] [Accepted: 03/22/2023] [Indexed: 05/22/2023]
Abstract
BACKGROUND Surgeons aim for R0 resection in patients with pancreatic cancer to improve overall survival. However, it is unclear whether recent changes in pancreatic cancer care such as centralization, increased use of neoadjuvant therapy, minimally invasive surgery, and standardized pathology reporting have influenced R0 resections and whether R0 resection remains associated with overall survival. METHODS This nationwide retrospective cohort study included consecutive patients after pancreatoduodenectomy (PD) for pancreatic cancer from the Netherlands Cancer Registry and the Dutch Nationwide Pathology Database (2009-2019). R0 resection was defined as > 1 mm tumor clearance at the pancreatic, posterior, and vascular resection margins. Completeness of pathology reporting was scored on the basis of six elements: histological diagnosis, tumor origin, radicality, tumor size, extent of invasion, and lymph node examination. RESULTS Among 2955 patients after PD for pancreatic cancer, the R0 resection rate was 49%. The R0 resection rate decreased from 68 to 43% (2009-2019, P < 0.001). The extent of resections in high-volume hospitals, minimally invasive surgery, neoadjuvant therapy, and complete pathology reports all significantly increased over time. Only complete pathology reporting was independently associated with lower R0 rates (OR 0.76, 95% CI 0.69-0.83, P < 0.001). Higher hospital volume, neoadjuvant therapy, and minimally invasive surgery were not associated with R0. R0 resection remained independently associated with improved overall survival (HR 0.72, 95% CI 0.66-0.79, P < 0.001), as well as in the 214 patients after neoadjuvant treatment (HR 0.61, 95% CI 0.42-0.87, P = 0.007). CONCLUSIONS The nationwide rate of R0 resections after PD for pancreatic cancer decreased over time, mostly related to more complete pathology reporting. R0 resection remained associated with overall survival.
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Affiliation(s)
- Simone Augustinus
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
| | - Pascale J M Schafrat
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Boris V Janssen
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Olivier R Busch
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Stijn Crobach
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Michail Doukas
- Department of Pathology, Erasmus Medical Center, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Lydia G M van der Geest
- Department of Research, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | | | - G Mihaela Raicu
- Department of Pathology, St Antonius Hospital and Pathology DNA, Nieuwegein, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, University Medical Center Utrecht, Utrecht & St. Antonius Hospital Nieuwegein, Utrecht, The Netherlands
| | | | - Joanne Verheij
- Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
| | - Arantza Farina Sarasqueta
- Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Amsterdam, The Netherlands.
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10
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Hopstaken JS, Vissers PAJ, Quispel R, de Vos-Geelen J, Brosens LAA, de Hingh IHJT, van der Geest LG, Besselink MG, van Laarhoven KJHM, Stommel MWJ. Impact of network treatment in patients with resected pancreatic cancer on use and timing of chemotherapy and survival. BJS Open 2023; 7:7156602. [PMID: 37151083 PMCID: PMC10165062 DOI: 10.1093/bjsopen/zrad006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 11/23/2022] [Accepted: 01/04/2023] [Indexed: 05/09/2023] Open
Abstract
BACKGROUND Centralization of pancreatic cancer surgery aims to improve postoperative outcomes. Consequently, patients with pancreatic cancer may undergo pancreatic surgery in an expert centre and adjuvant chemotherapy in a local hospital (network treatment). The aim of this study was to assess whether network treatment has an impact on time to chemotherapy, failure to complete adjuvant chemotherapy, and survival. Second, whether these parameters varied between pancreatic networks was studied. METHODS This retrospective study included all patients diagnosed with non-metastatic pancreatic ductal adenocarcinoma who underwent pancreatic surgery and adjuvant chemotherapy, registered in the Netherlands Cancer Registry (2015-2020). Time to chemotherapy was defined as the time between surgery and the start of adjuvant chemotherapy. Completion of adjuvant chemotherapy was defined as the receipt of 12 cycles of FOLFIRINOX or six cycles of gemcitabine. Analysis was performed with linear mixed models and multilevel logistic regression models. Cox regression analyses were performed for survival. RESULTS In total, 1074 patients were included. Network treatment was observed in 468 patients (43.6 per cent) and was not associated with longer time to chemotherapy (0.77 days, standard error (s.e.) 1.14, P = 0.501), failure to complete adjuvant chemotherapy (odds ratio (OR) = 1.140, 95 per cent c.i. 0.86 to 1.52, P = 0.349), and overall survival (hazards ratio (HR) = 1.04, 95 per cent c.i. 0.88 to 1.22, P = 0.640). Significant variation between the networks was observed for time to chemotherapy (range 40.5-63 days, P < 0.0001) and completion of adjuvant chemotherapy (range 19-52 per cent, P = 0.030). Adjusted for case mix, time to chemotherapy significantly differed between networks. CONCLUSION In this nationwide analysis, network treatment in patients with resected pancreatic cancer was not associated with longer time to chemotherapy, failure to complete adjuvant chemotherapy, and worse survival. Significant variation between pancreatic cancer networks was found for time to chemotherapy.
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Affiliation(s)
- Jana S Hopstaken
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Pauline A J Vissers
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
| | - Rutger Quispel
- Department of Gastroenterology and Hepatology, Reinier de Graaf Groep, Delft, The Netherlands
| | - Judith de Vos-Geelen
- Department of Internal Medicine, Division of Medical Oncology, Maastricht University Medical Center, GROW, Maastricht University, Maastricht, The Netherlands
| | - Lodewijk A A Brosens
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Pathology, UMC Utrecht, Utrecht, The Netherlands
| | | | - Lydia G van der Geest
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | | | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
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11
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Kim RC, Allen KA, Roch AM, McGuire SP, Ceppa EP, Zyromski NJ, Nakeeb A, House MG, Schmidt CM, Nguyen TK. Neoadjuvant therapy at local versus outside institutions does not adversely impact surgical timing or long-term outcomes in patients with pancreatic adenocarcinoma. Surgery 2023; 173:574-580. [PMID: 36253310 DOI: 10.1016/j.surg.2022.06.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/10/2022] [Accepted: 06/21/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Although high-volume centers are known to have better surgical outcomes, patients with pancreatic adenocarcinoma often receive chemotherapy at treatment centers closer to home. This study aimed to determine whether treatment site of neoadjuvant therapy relative to surgery location impacts surgical timing and long-term outcomes. METHODS All patients with pancreatic adenocarcinoma who underwent oncologic resection at a single, high-volume institution between January 2016 and February 2020 and had neoadjuvant chemotherapy before surgery were queried from a prospectively maintained database. Patients were sorted based on location of neoadjuvant chemotherapy. RESULTS A total of 179 patients were included in the study. Seventy-four (41.3%) patients received neoadjuvant chemotherapy at the same institution as their surgery (group A), 20 (11.2%) received chemotherapy outside of their surgical institution but within the same hospital/healthcare system (group B), and 85 (47.5%) received chemotherapy at an outside location (group C). The time from completion of neoadjuvant therapy to surgery was not significantly different between groups (A vs B vs C median [interquartile range]: 34.5 [14] vs 41.5 [24] vs 36 [22] days, P = .08). Thirty-day readmission rate was lower in group A (n (%): 1 (1.4%) vs 2 (10.0%) vs 11 (12.9%), P = .02). However, the 90-day mortality and overall survival did not differ significantly between groups. CONCLUSION Patients may receive neoadjuvant therapy at local centers without impacting surgical scheduling. Although these patients may experience higher postoperative readmission rates, perioperative mortality and long-term survival are not adversely affected by location of chemotherapy. Multidisciplinary care can be effectively practiced in different locations without affecting overall outcomes in patients with pancreatic adenocarcinoma.
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Affiliation(s)
- Rachel C Kim
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Kara A Allen
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Alexandra M Roch
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Sean P McGuire
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Eugene P Ceppa
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Nicholas J Zyromski
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Attila Nakeeb
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Michael G House
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - C Max Schmidt
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Trang K Nguyen
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN.
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12
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Yan Y, Hua Y, Chang C, Zhu X, Sha Y, Wang B. Laparoscopic versus open pancreaticoduodenectomy for pancreatic and periampullary tumor: A meta-analysis of randomized controlled trials and non-randomized comparative studies. Front Oncol 2023; 12:1093395. [PMID: 36761416 PMCID: PMC9905842 DOI: 10.3389/fonc.2022.1093395] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 12/30/2022] [Indexed: 01/27/2023] Open
Abstract
Objective This meta-analysis compares the perioperative outcomes of laparoscopic pancreaticoduodenectomy (LPD) to those of open pancreaticoduodenectomy (OPD) for pancreatic and periampullary tumors. Background LPD has been increasingly applied in the treatment of pancreatic and periampullary tumors. However, the perioperative outcomes of LPD versus OPD are still controversial. Methods PubMed, Web of Science, EMBASE, and the Cochrane Library were searched to identify randomized controlled trials (RCTs) and non-randomized comparative trials (NRCTs) comparing LPD versus OPD for pancreatic and periampullary tumors. The main outcomes were mortality, morbidity, serious complications, and hospital stay. The secondary outcomes were operative time, blood loss, transfusion, postoperative pancreatic fistula (POPF), postpancreatectomy hemorrhage (PPH), bile leak (BL), delayed gastric emptying (DGE), lymph nodes harvested, R0 resection, reoperation, and readmission. RCTs were evaluated by the Cochrane risk-of-bias tool. NRCTs were assessed using a modified tool from the Methodological Index for Non-randomized Studies. Data were pooled as odds ratio (OR) or mean difference (MD). This study was registered at PROSPERO (CRD42022338832). Results Four RCTs and 35 NRCTs concerning a total of 40,230 patients (4,262 LPD and 35,968 OPD) were included. Meta-analyses showed no significant differences in mortality (OR 0.91, p = 0.35), serious complications (OR 0.97, p = 0.74), POPF (OR 0.93, p = 0.29), PPH (OR 1.10, p = 0.42), BL (OR 1.28, p = 0.22), harvested lymph nodes (MD 0.66, p = 0.09), reoperation (OR 1.10, p = 0.41), and readmission (OR 0.95, p = 0.46) between LPD and OPD. Operative time was significantly longer for LPD (MD 85.59 min, p < 0.00001), whereas overall morbidity (OR 0.80, p < 0.00001), hospital stay (MD -2.32 days, p < 0.00001), blood loss (MD -173.84 ml, p < 0.00001), transfusion (OR 0.62, p = 0.0002), and DGE (OR 0.78, p = 0.002) were reduced for LPD. The R0 rate was higher for LPD (OR 1.25, p = 0.001). Conclusions LPD is associated with non-inferior short-term surgical outcomes and oncologic adequacy compared to OPD when performed by experienced surgeons at large centers. LPD may result in reduced overall morbidity, blood loss, transfusion, and DGE, but longer operative time. Further RCTs should address the potential advantages of LPD over OPD. Systematic review registration PROSPERO, identifier CRD42022338832.
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Affiliation(s)
- Yong Yan
- Department of General Surgery, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, China
| | - Yinggang Hua
- Department of General Surgery, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, China
| | - Cheng Chang
- Department of General Surgery, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, China
| | - Xuanjin Zhu
- Department of General Surgery, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, China
| | - Yanhua Sha
- Department of Laboratory Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China,*Correspondence: Yanhua Sha, ; Bailin Wang,
| | - Bailin Wang
- Department of General Surgery, Guangzhou Red Cross Hospital, Jinan University, Guangzhou, China,*Correspondence: Yanhua Sha, ; Bailin Wang,
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13
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Ramia JM, Cugat E, De la Plaza R, Gomez-Bravo MA, Martín E, Muñoz-Bellvis L, Padillo FJ, Sabater L, Serradilla-Martín M. Clinical decisions in pancreatic cancer surgery: a national survey and case-vignette study. Updates Surg 2023; 75:115-131. [PMID: 36376560 DOI: 10.1007/s13304-022-01415-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 10/31/2022] [Indexed: 11/16/2022]
Abstract
Very few surveys have been carried out of oncosurgical decisions made in patients with pancreatic cancer (PC), or of the possible differences in therapeutic approaches between low/medium and high-volume centers. A survey was sent out to centers affiliated to the Spanish Group of Pancreatic Surgery (GECP) asking about their usual pre-, intra- and post-operative management of PC patients and describing five imaginary cases of PC corresponding to common scenarios that surgeons regularly assess in oncosurgical meetings. A consensus was considered to have been reached when 80% of the answers coincided. We received 69 responses from the 72 GECP centers (response rate 96%). Pre-operative management: consensus was obtained on 7/16 questions (43.75%) with no significant differences between low- vs high-volume centers. Intra-operative: consensus was obtained on 11/28 questions (39.3%). D2 lymphadenectomy, biliary culture, intra-operative biliary margin study, pancreatojejunostomy, and two loops were significantly more frequent in high-volume hospitals (p < 0.05). Post-operative: consensus was obtained on 2/8 questions (25%). No significant differences were found between low-/medium- vs high-volume hospitals. Of the 41 questions asked regarding the cases, consensus was reached on 22 (53.7%). No differences in the responses were found according to the type of hospital. Management and cases: consensus was reached in 42/93 questions (45.2%). At GECP centers, consensus was obtained on 45% of the questions. Only 5% of the answers differed between low/medium and high-volume centers (all intra-operative). A more specific assessment of why high-volume centers obtain the best results would require the design of complex prospective studies able to measure the therapeutic decisions made and the effectiveness of their execution. Clinicaltrials.gov identifier: NCT04755036.
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Affiliation(s)
- Jose M Ramia
- Department of Surgery, Hospital General Universitario de Alicante, Sol Naciente 8, 16D, 03016, Alicante, Spain. .,Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain.
| | - Esteban Cugat
- Department of Surgery, Hospital Universitario Germans Trias i Puyol and Hospital Universitario Mútua Terrassa, Barcelona, Spain
| | - Roberto De la Plaza
- Department of Surgery, Hospital Universitario de Guadalajara, Guadalajara, Spain
| | | | - Elena Martín
- Department of Surgery, Hospital Universitario La Princesa, Madrid, Spain
| | - Luis Muñoz-Bellvis
- Department of Surgery, University Hospital of Salamanca, Salamanca, Spain.,Institute of Biomedical Research of Salamanca (IBSAL), Universidad de Salamanca and Biomedical Research Networking Centre Consortium-CIBER-CIBERONC, Salamanca, Spain
| | - Francisco J Padillo
- Department of Surgery, Hospital Universitario Virgen del Rocio, Seville, Spain
| | - Luis Sabater
- Department of Surgery, Hospital Clínico, Biomedical Research Institute, University of Valencia, Valencia, Spain
| | - Mario Serradilla-Martín
- Department of Surgery, Instituto de Investigación Sanitaria Aragón, Hospital Universitario Miguel Servet, Zaragoza, Spain
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14
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Takamoto T, Nara S, Ban D, Mizui T, Murase Y, Esaki M, Shimada K. Chronological improvement of pancreatectomy for resectable but advanced pancreatic neuroendocrine neoplasms. Pancreatology 2022; 22:1141-1147. [PMID: 36404199 DOI: 10.1016/j.pan.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 10/17/2022] [Accepted: 11/06/2022] [Indexed: 11/14/2022]
Abstract
BACKGROUND Progress of non-surgical treatments in the last decade has improved the prognosis of pancreatic neuroendocrine neoplasms (PanNEN). However, the improvement of surgery for advanced PanNEN remains unknown. This study aimed to investigate the chronological changes of the clinical impact of pancreatectomy for PanNEN. METHODS Patients undergoing curative-intent pancreatectomy for PanNEN between 1991 and 2010 were categorized into the earlier period group, and those between 2011 and 2021 were into the later period group. Advanced PanNEN was defined as showing resectable synchronous liver metastases or invasion to portal venous systems or adjacent organs. The recurrence-free survival (RFS) and overall survival (OS) were analyzed among patients with non-advanced and advanced PanNENs. The independent prognostic risk factors were identified using a Cox proportional hazard model. RESULTS A total of 189 patients (n = 54 in the earlier period and n = 135 in the later period) were included. The proportion of advanced PanNEN increased from 15% to 30% (P = 0.027). The RFS and OS of non-advanced PanNEN were similar between the periods. Whereas, among patients with advanced PanNEN, the later period group showed improved prognosis; The 5-year RFS of the earlier period vs. the later period was 0% vs. 27%, and the 5-year OS was 38% vs. 82% (p = 0.013). CONCLUSIONS A radical surgical treatment for advanced PanNEN has shown prognostic improvement in this decade. However, more careful perioperative examinations and possibly, additional treatments are required for PanNEN with portal vein invasion.
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Affiliation(s)
- Takeshi Takamoto
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, Tokyo, Japan.
| | - Satoshi Nara
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Daisuke Ban
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Takahiro Mizui
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Yoshiki Murase
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Minoru Esaki
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Kazuaki Shimada
- Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center Hospital, Tokyo, Japan
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15
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Kwak HV, Hsu DS, Le ST, Chang AL, Spitzer AL, Kazantsev GB, Peng PD, Chang CK. Pancreatic Neuroendocrine Tumor: Rationale for Centralization in an Integrated Health Care System. Pancreas 2022; 51:1332-1336. [PMID: 37099775 DOI: 10.1097/mpa.0000000000002194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Abstract
OBJECTIVES Given the complex surgical management and infrequency of pancreatic neuroendocrine tumor, we hypothesized that treatment at a center of excellence improves survival. METHODS Retrospective review identified 354 patients with pancreatic neuroendocrine tumor treated between 2010 and 2018. Four hepatopancreatobiliary centers of excellence were created from 21 hospitals throughout Northern California. Univariate and multivariate analyses were performed. The χ2 test of clinicopathologic factors determined which were predictive for overall survival (OS). RESULTS Localized disease was seen in 51% of patients, and metastatic disease was seen in 32% of patients with mean OS of 93 and 37 months, respectively (P < 0.001). On multivariate survival analysis, stage, tumor location, and surgical resection were significant for OS (P < 0.001). All stage OS for patients treated at designated centers was 80 and 60 months for noncenters (P < 0.001). Surgery was more common across stages at the centers of excellence versus noncenters at 70% and 40%, respectively (P < 0.001). CONCLUSIONS Pancreatic neuroendocrine tumors are indolent but have malignant potential at any size with management often requiring complex surgeries. We showed survival was improved for patients treated at a center of excellence, where surgery was more frequently utilized.
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Affiliation(s)
- Hyunjee V Kwak
- From the Department of Surgery, University of California San Francisco-East Bay, Oakland, CA
| | - Diana S Hsu
- From the Department of Surgery, University of California San Francisco-East Bay, Oakland, CA
| | - Sidney T Le
- From the Department of Surgery, University of California San Francisco-East Bay, Oakland, CA
| | | | - Austin L Spitzer
- Department of Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA
| | - George B Kazantsev
- Department of Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA
| | - Peter D Peng
- Department of Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA
| | - Ching-Kuo Chang
- Department of Surgery, Kaiser Permanente Oakland Medical Center, Oakland, CA
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16
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Hopstaken JS, Vissers PAJ, Quispel R, de Vos-Geelen J, Brosens LAA, de Hingh IHJT, van der Geest LG, Besselink MG, van Laarhoven KJHM, Stommel MWJ. Impact of multicentre diagnostic workup in patients with pancreatic cancer on repeated diagnostic investigations, time-to-diagnosis and time-to-treatment: A nationwide analysis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:2195-2201. [PMID: 35701256 DOI: 10.1016/j.ejso.2022.05.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 05/04/2022] [Accepted: 05/28/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Due to the centralization of pancreatic surgery, patients with suspected pancreatic cancer may undergo diagnostic workup in both a non-pancreatic centre and a pancreatic centre, i.e. multicentre workup. This retrospective study assessed whether multicentre diagnostic workup is associated with repeated diagnostics, delayed time-to-diagnosis, delayed time-to-treatment, survival and whether variation existed among pancreatic cancer networks. METHODS This nationwide study included all patients diagnosed with non-metastatic pancreatic ductal adenocarcinoma (PDAC) in 2015, registered by the Netherlands Cancer Registry. A delayed time-to-diagnosis was defined as ≥3 weeks from initial hospital visit to final diagnosis. A delayed time-to-treatment was defined as ≥6 weeks from the first hospital visit to start of first tumour treatment. Multilevel logistic regression analyses and survival analyses were performed. RESULTS In total, 931 patients with non-metastatic PDAC were included. Overall, 175 patients (19%) underwent a multicentre diagnostic workup, which was significantly associated with repeated diagnostic investigations (OR = 6.31, 95% CI 4.13-9.64, P < 0.0001), a delayed time-to-diagnosis (OR = 2.66 95% CI 1.74-4.06, P < 0.001), and a delayed time-to-treatment (OR = 1.93 95% CI 1.12-3.31, P = 0.02), but not with decreased survival (HR = 1.09 95% CI 0.83-1.44; P = 0.532). Variation in outcomes per network was observed, especially for time-to-treatment, though the ICC was not statistically significant (P = 0.065). CONCLUSION Multicentre diagnostic workup for patients with PDAC is associated with repeated diagnostic investigations, a delayed time-to-diagnosis and delayed time-to-treatment compared to patients with monocentre workup. To reduce costs and improve treatment times, efforts should be made to improve network coordination, for example via network care pathways.
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Affiliation(s)
- Jana S Hopstaken
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands; Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Pauline A J Vissers
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands; Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands
| | - Rutger Quispel
- Department of Gastroenterology and Hepatology, Reinier de Graaf Groep, Delft, the Netherlands
| | - Judith de Vos-Geelen
- Department of Internal Medicine, Division of Medical Oncology, GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Lodewijk A A Brosens
- Department of Pathology, Radboud University Medical Center, Nijmegen, the Netherlands, Department of Pathology, UMC Utrecht, Utrecht, the Netherlands
| | | | - Lydia G van der Geest
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, the Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | | | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands.
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17
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Trends in pancreatic surgery in Switzerland: a survey and nationwide analysis over two decades. Langenbecks Arch Surg 2022; 407:3423-3435. [DOI: 10.1007/s00423-022-02679-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 09/08/2022] [Indexed: 12/24/2022]
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18
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Ignatavicius P, Oberkofler CE, Jonas JP, Mullhaupt B, Clavien PA. The essential requirements for an HPB centre to deliver high-quality outcomes. J Hepatol 2022; 77:837-848. [PMID: 35577030 DOI: 10.1016/j.jhep.2022.04.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 04/12/2022] [Accepted: 04/27/2022] [Indexed: 12/04/2022]
Abstract
The concept of a centre approach to the treatment of patients with complex disorders, such as those with hepato-pancreato-biliary (HPB) diseases, is widely applied, although what is needed for an HPB centre to achieve high-quality outcomes remains unclear. We therefore conducted a literature review, which highlighted the paucity of information linking centre structure or process to outcome data outside of caseloads, specialisation, and quality of training. We then conducted an international survey among the largest 107 HPB centres with experts in HPB surgery and found that most responders work in 'virtual' HPB centres without dedicated space, assigned beds, nor personal. We finally analysed our experience with the Swiss HPB centre, previously reported in this journal 15 years ago, disclosing that budget priorities set by the hospital administration may prevent the development of a fully integrated centre, for example through inconsistent assignment of the centre's beds to HBP patients or removal of dedicated intermediate care beds. We propose criteria for essential requirements for an HPB centre to deliver high-quality outcomes, with the concept of "centre of reference" limited to actual, as opposed to virtual, centres.
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Affiliation(s)
- Povilas Ignatavicius
- Swiss Hepato-Pancreato-Biliary (HPB) Center Zurich, Zurich, Switzerland; Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Christian E Oberkofler
- Swiss Hepato-Pancreato-Biliary (HPB) Center Zurich, Zurich, Switzerland; Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Jan Philipp Jonas
- Swiss Hepato-Pancreato-Biliary (HPB) Center Zurich, Zurich, Switzerland; Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Beat Mullhaupt
- Swiss Hepato-Pancreato-Biliary (HPB) Center Zurich, Zurich, Switzerland; Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Pierre-Alain Clavien
- Swiss Hepato-Pancreato-Biliary (HPB) Center Zurich, Zurich, Switzerland; Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland.
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19
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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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20
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Hsu DS, Kumar NS, Le ST, Chang AL, Kazantsev G, Spitzer AL, Peng PD, Chang CK. Centralization of pancreatic cancer treatment within an integrated healthcare system improves overall survival. Am J Surg 2022; 223:1035-1039. [PMID: 34607651 DOI: 10.1016/j.amjsurg.2021.09.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 09/11/2021] [Accepted: 09/29/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Higher-volume centers for pancreatic cancer surgeries have been shown to have improved outcomes such as length of stay. We examined how centralization of pancreatic cancer care within a regional integrated healthcare system improves overall survival. METHODS We conducted a retrospective study of 1621 patients treated for pancreatic cancer from February 2010 to December 2018. Care was consolidated into 4 Centers of Excellence (COE) in surgery, medical oncology, and other specialties. Descriptive statistics, bivariate analysis, Chi-square tests, and Kaplan-Meier analysis were performed. RESULTS Neoadjuvant chemotherapy use rose from 10% to 31% (p < .001). The median overall survival (OS) improved by 3 months after centralization (p < .001), but this did not reach significance on multivariate analysis. CONCLUSIONS Our results suggest that in a large integrated healthcare system, centralization improves overall survival and neoadjuvant therapy utilization for pancreatic cancer patients.
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Affiliation(s)
- Diana S Hsu
- University of California, San Francisco - East Bay Surgery, Highland Hospital, 1411 E 31st St, Q1C 22134, Oakland, CA, 94602, USA; Department of Surgery, Kaiser Permanente-Oakland Medical Center, 3600 Broadway, Oakland, CA, 94611, USA.
| | - Nikathan S Kumar
- University of California, San Francisco - East Bay Surgery, Highland Hospital, 1411 E 31st St, Q1C 22134, Oakland, CA, 94602, USA; Department of Surgery, Kaiser Permanente-Oakland Medical Center, 3600 Broadway, Oakland, CA, 94611, USA
| | - Sidney T Le
- University of California, San Francisco - East Bay Surgery, Highland Hospital, 1411 E 31st St, Q1C 22134, Oakland, CA, 94602, USA; Department of Surgery, Kaiser Permanente-Oakland Medical Center, 3600 Broadway, Oakland, CA, 94611, USA
| | - Alex L Chang
- Department of Surgery, Kaiser Permanente-Oakland Medical Center, 3600 Broadway, Oakland, CA, 94611, USA
| | - George Kazantsev
- Department of Surgery, Kaiser Permanente-Oakland Medical Center, 3600 Broadway, Oakland, CA, 94611, USA
| | - Austin L Spitzer
- Department of Surgery, Kaiser Permanente-Oakland Medical Center, 3600 Broadway, Oakland, CA, 94611, USA
| | - Peter D Peng
- Department of Surgery, Kaiser Permanente-Oakland Medical Center, 3600 Broadway, Oakland, CA, 94611, USA
| | - Ching-Kuo Chang
- Department of Surgery, Kaiser Permanente-Oakland Medical Center, 3600 Broadway, Oakland, CA, 94611, USA
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21
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Ramirez G, Myers TG, Thirukumaran CP, Ricciardi BF. Does Hypothetical Centralization of Revision THA and TKA Exacerbate Existing Geographic or Demographic Disparities in Access to Care by Increased Patient Travel Distances or Times? A Large-database Study. Clin Orthop Relat Res 2022; 480:1033-1045. [PMID: 34870619 PMCID: PMC9263467 DOI: 10.1097/corr.0000000000002072] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 11/08/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Higher hospital volume is associated with lower rates of adverse outcomes after revision total joint arthroplasty (TJA). Centralizing revision TJA care to higher-volume hospitals might reduce early complication and readmission rates after revision TJA; however, the effect of centralizing revision TJA care on patient populations who are more likely to experience challenges with access to care is unknown. QUESTIONS/PURPOSES (1) Does a hypothetical policy of transferring patients undergoing revision TJA from lower-to higher-volume hospitals increase patient travel distance and time? (2) Does a hypothetical policy of transferring patients undergoing revision TJA from lower- to higher-volume hospitals disproportionately affect travel distance or time in low income, rural, or racial/ethnic minority populations? METHODS Using the Medicare Severity Diagnosis Related Groups 466-468, we identified 37,147 patients with inpatient stays undergoing revision TJA from 2008 to 2016 in the Statewide Planning and Research Cooperative System administrative database for New York State. Revisions with missing or out-of-state patient identifiers (3474 of 37,147) or those associated with closed or merged facilities (180 of 37,147) were excluded. We chose this database for our study because of relative advantages to other available databases: comprehensive catchment of all surgical procedures in New York State, regardless of payer; each patient can be followed across episodes of care and hospitals in New York State; and New York State has an excellent cross-section of hospital types for TJA, including rural and urban hospitals, critical access hospitals, and some of the highest-volume centers for TJA in the United States. We divided hospitals into quartiles based on the mean revision TJA volume. Overall, 80% (118 of 147) of hospitals were not for profit, 18% (26 of 147) were government owned, 78% (115 of 147) were located in urban areas, and 48% (70 of 147) had fewer than 200 beds. The mean patient age was 66 years old, 59% (19,888 of 33,493) of patients were females, 79% (26,376 of 33,493) were white, 82% (27,410 of 33,493) were elective admissions, and 56% (18,656 of 33,493) of admissions were from government insurance. Three policy scenarios were evaluated: transferring patients from the lowest 25% by volume hospitals, transferring patients in the lowest 50% by volume hospitals, and transferring patients in the lowest 75% by volume hospitals to the nearest higher-volume institution by distance. Patients who changed hospitals and travelled more than 60 miles or longer than 60 minutes with consideration for average traffic patterns after the policy was enacted were considered adversely affected. The secondary outcome of interest was the impact of the three centralization policies, as defined above, on lower-income, nonwhite, rural versus urban counties, and Hispanic ethnicity. RESULTS Transferring patients from the lowest 25% by volume hospitals resulted in only one patient stay that was affected by an increase in travel distance and travel time. Transferring patients from the lowest 50% by volume hospitals resulted in 9% (3050 of 33,493) of patients being transferred, with only 1% (312 of 33,493) of patients affected by either an increased travel distance or travel time. Transferring patients from the lowest 75% by volume hospitals resulted in 28% (9323 of 33,493) of patients being transferred, with 2% (814 of 33,493) of patients affected by either an increased travel distance or travel time. Nonwhite patients were less likely to encounter an increased travel distance or time after being transferred from the lowest 50% by volume hospitals (odds ratio 0.31 [95% CI 0.15 to 0.65]; p = 0.002) or being transferred from the lowest 75% by volume hospitals (OR 0.10 [95% CI 0.07 to 0.15]; p < 0.001) than white patients were. Hispanic patients were more likely to experience increased travel distance or time after being transferred from the lowest 50% by volume hospitals (OR 12.3 [95% CI 5.04 to 30.2]; p < 0.001) and being transferred from the lowest 75% by volume hospitals (OR 3.24 [95% CI 2.24 to 4.68]; p < 0.001) than non-Hispanic patients were. Patients from a county with a lower median income were more likely to experience increased travel distances or time after being transferred from the lowest 50% by volume hospitals (OR 69.5 [95% CI 17.0 to 283]; p < 0.001) and being transferred from the lowest 75% by volume hospitals (OR 3.86 [95% CI 3.21 to 4.64]; p < 0.001) than patients from counties with a higher median income. Patients from rural counties were more likely to be affected after being transferred from the lowest 50% by volume hospitals (OR 98 [95% CI 49.6 to 192.2]; p < 0.001) and being transferred from the lowest 75% by volume hospitals (OR 11.7 [95% CI 9.89 to 14.0]; p < 0.001) than patients from urban counties. CONCLUSION Although centralizing revision TJA care to higher-volume institutions in New York State did not appear to increase the travel burden for most patients, policies that centralize revision TJA care will need to be carefully designed to minimize the disproportionate impact on patient populations that already face challenges with access to healthcare. Further studies should examine the feasibility of establishing centers of excellence designations for revision TJA, the effect of best practices adoption by lower volume institutions to improve revision TJA care, and the potential role of care-extending technology such as telemedicine to improve access to care to reduce the effects of travel distances on affected patient populations. LEVEL OF EVIDENCE Level III, prognostic study.
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Affiliation(s)
- Gabriel Ramirez
- Department of Orthopedic Surgery, University of Rochester School of Medicine, Rochester, NY, USA
- Center for Musculoskeletal Research, Department of Orthopedic Surgery, University of Rochester School of Medicine, Rochester, NY, USA
| | - Thomas G. Myers
- Department of Orthopedic Surgery, University of Rochester School of Medicine, Rochester, NY, USA
| | - Caroline P. Thirukumaran
- Department of Orthopedic Surgery, University of Rochester School of Medicine, Rochester, NY, USA
- Center for Musculoskeletal Research, Department of Orthopedic Surgery, University of Rochester School of Medicine, Rochester, NY, USA
| | - Benjamin F. Ricciardi
- Department of Orthopedic Surgery, University of Rochester School of Medicine, Rochester, NY, USA
- Center for Musculoskeletal Research, Department of Orthopedic Surgery, University of Rochester School of Medicine, Rochester, NY, USA
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22
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Perinel J, Nappo G, Zerbi A, Heidsma CM, Nieveen van Dijkum EJM, Han HS, Yoon YS, Satoi S, Demir IE, Friess H, Vashist Y, Izbicki J, Muller AC, Gloor B, Sandini M, Gianotti L, Subtil F, Adham M. Sporadic nonfunctional pancreatic neuroendocrine tumors: Risk of lymph node metastases and aggressiveness according to tumor size: A multicenter international study. Surgery 2022; 172:975-981. [PMID: 35623953 DOI: 10.1016/j.surg.2022.04.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 03/25/2022] [Accepted: 04/06/2022] [Indexed: 01/08/2023]
Abstract
BACKGROUND Although the correlation between tumor size and aggressiveness is clearly established in sporadic nonfunctional pancreatic neuroendocrine tumors, the management of tumors ≤2 cm remains debated. In recent guidelines, the cut-off size to operate ranged from 1 to 2 cm. The aim of this retrospective study was to report the rate of lymph nodes metastases in resected sporadic nonfunctional pancreatic neuroendocrine tumors, according to tumor size and, second, to identify risk factors of lymph node metastases and disease-free survival. METHODS Resected sporadic nonfunctional pancreatic neuroendocrine tumors from 9 international expert centers were included (1999-2017). Functional pancreatic neuroendocrine tumors, genetic syndromes, and R2 resection were excluded. Aggressiveness was defined as microvascular invasion, perineural invasion, lymph node metastases, G3 grading, distant metastases, and/or recurrence. RESULTS Overall, 495 resected sporadic nonfunctional pancreatic neuroendocrine tumors were included. For tumors up to 5 cm, the risk of lymph node metastases was increased by 1.73 for every 1 cm increase in size (odds ratio = 1.73; 95% confidence interval = 1.46-2.03). Tumor size >2 cm (P < .001), perineural invasion (P = .002), microvascular invasion (P < .001), and distant metastases (P = .008) were independently associated with lymph node metastases. Tumor size >2 cm (P = .003), R1 status (P = .004), lymph node metastases (P < .001), and World Health Organization grade 3 (P = .002) were independently associated with disease-free survival. Aggressiveness rate was 13.1% in tumors ≤1 cm and 29% in tumors between 1.1 and 2 cm. CONCLUSION In resected sporadic nonfunctional pancreatic neuroendocrine tumors, the risk of lymph node metastases is correlated to tumor size. Considering that sporadic nonfunctional pancreatic neuroendocrine tumors between 1.1 and 2 cm had a higher risk of lymph node metastases and recurrence compared to tumors ≤1 cm, the decision to perform surgery in this subgroup of patients should be individualized in surgically fit patients.
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Affiliation(s)
- Julie Perinel
- Department of Digestive Surgery, E. Herriot Hospital, Hospices Civils de Lyon, Lyon Sud Faculty of Medicine, UCBL1, Lyon, France.
| | - Gennaro Nappo
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center-IRCCS Rozzano, Milan, Italy
| | - Alessandro Zerbi
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center-IRCCS Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Charlotte M Heidsma
- Department of Surgery, Amsterdam University Medical Center, University of Amsterdam, The Netherlands
| | | | - Ho Seong Han
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Republic of Korea
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Republic of Korea
| | - Sohei Satoi
- Department of Surgery, Kansai Medical University, Osaka, Japan; Division of Surgical Oncology, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Ihsan Ekin Demir
- Department of Surgery, Technical University Munich Faculty of Medicine, Munchen, Germany
| | - Helmut Friess
- Department of Surgery, Technical University Munich Faculty of Medicine, Munchen, Germany
| | - Yogesh Vashist
- Medias Klinikum, Centre for Surgical Oncology, Burghausen, Germany
| | - Jakob Izbicki
- General, Visceral, and Thoracic Surgery Department, Clinic University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Beat Gloor
- University Hospital Bern Inselspital Bern, Switzerland
| | - Marta Sandini
- School of Medicine and Surgery, University of Milano-Bicocca and Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Luca Gianotti
- School of Medicine and Surgery, University of Milano-Bicocca and Department of Surgery, San Gerardo Hospital, Monza, Italy
| | - Fabien Subtil
- UCBLUMR CNRS 5558 - LBBE, Service de Biostatistiques, Hospices Civils de Lyon, France
| | - Mustapha Adham
- Department of Digestive Surgery, E. Herriot Hospital, Hospices Civils de Lyon, Lyon Sud Faculty of Medicine, UCBL1, Lyon, France
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23
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Smits FJ, Henry AC, Besselink MG, Busch OR, van Eijck CH, Arntz M, Bollen TL, van Delden OM, van den Heuvel D, van der Leij C, van Lienden KP, Moelker A, Bonsing BA, Borel Rinkes IH, Bosscha K, van Dam RM, Derksen WJM, den Dulk M, Festen S, Groot Koerkamp B, de Haas RJ, Hagendoorn J, van der Harst E, de Hingh IH, Kazemier G, van der Kolk M, Liem M, Lips DJ, Luyer MD, de Meijer VE, Mieog JS, Nieuwenhuijs VB, Patijn GA, Te Riele WW, Roos D, Schreinemakers JM, Stommel MWJ, Wit F, Zonderhuis BA, Daamen LA, van Werkhoven CH, Molenaar IQ, van Santvoort HC. Algorithm-based care versus usual care for the early recognition and management of complications after pancreatic resection in the Netherlands: an open-label, nationwide, stepped-wedge cluster-randomised trial. Lancet 2022; 399:1867-1875. [PMID: 35490691 DOI: 10.1016/s0140-6736(22)00182-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 12/09/2021] [Accepted: 12/16/2021] [Indexed: 10/18/2022]
Abstract
BACKGROUND Early recognition and management of postoperative complications, before they become clinically relevant, can improve postoperative outcomes for patients, especially for high-risk procedures such as pancreatic resection. METHODS We did an open-label, nationwide, stepped-wedge cluster-randomised trial that included all patients having pancreatic resection during a 22-month period in the Netherlands. In this trial design, all 17 centres that did pancreatic surgery were randomly allocated for the timing of the crossover from usual care (the control group) to treatment given in accordance with a multimodal, multidisciplinary algorithm for the early recognition and minimally invasive management of postoperative complications (the intervention group). Randomisation was done by an independent statistician using a computer-generated scheme, stratified to ensure that low-medium-volume centres alternated with high-volume centres. Patients and investigators were not masked to treatment. A smartphone app was designed that incorporated the algorithm and included the daily evaluation of clinical and biochemical markers. The algorithm determined when to do abdominal CT, radiological drainage, start antibiotic treatment, and remove abdominal drains. After crossover, clinicians were trained in how to use the algorithm during a 4-week wash-in period; analyses comparing outcomes between the control group and the intervention group included all patients other than those having pancreatic resection during this wash-in period. The primary outcome was a composite of bleeding that required invasive intervention, organ failure, and 90-day mortality, and was assessed by a masked adjudication committee. This trial was registered in the Netherlands Trial Register, NL6671. FINDINGS From Jan 8, 2018, to Nov 9, 2019, all 1805 patients who had pancreatic resection in the Netherlands were eligible for and included in this study. 57 patients who underwent resection during the wash-in phase were excluded from the primary analysis. 1748 patients (885 receiving usual care and 863 receiving algorithm-centred care) were included. The primary outcome occurred in fewer patients in the algorithm-centred care group than in the usual care group (73 [8%] of 863 patients vs 124 [14%] of 885 patients; adjusted risk ratio [RR] 0·48, 95% CI 0·38-0·61; p<0·0001). Among patients treated according to the algorithm, compared with patients who received usual care there was a decrease in bleeding that required intervention (47 [5%] patients vs 51 [6%] patients; RR 0·65, 0·42-0·99; p=0·046), organ failure (39 [5%] patients vs 92 [10%] patients; 0·35, 0·20-0·60; p=0·0001), and 90-day mortality (23 [3%] patients vs 44 [5%] patients; 0·42, 0·19-0·92; p=0·029). INTERPRETATION The algorithm for the early recognition and minimally invasive management of complications after pancreatic resection considerably improved clinical outcomes compared with usual care. This difference included an approximate 50% reduction in mortality at 90 days. FUNDING The Dutch Cancer Society and UMC Utrecht.
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Affiliation(s)
- F Jasmijn Smits
- Department of Surgery, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | - Anne Claire Henry
- Department of Surgery, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | - Marc G Besselink
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Olivier R Busch
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Casper H van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Mark Arntz
- Department of Radiology, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Thomas L Bollen
- Department of Radiology, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | - Otto M van Delden
- Department of Radiology, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Daniel van den Heuvel
- Department of Radiology, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | | | - Krijn P van Lienden
- Department of Radiology, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | - Adriaan Moelker
- Department of Radiology and Nuclear Medicine, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Centre, Leiden, Netherlands
| | - Inne H Borel Rinkes
- Department of Surgery, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, Den Bosch, Netherlands
| | - Ronald M van Dam
- Department of Surgery, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Wouter J M Derksen
- Department of Surgery, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | - Marcel den Dulk
- Department of Surgery, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Sebastiaan Festen
- Department of Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, Netherlands
| | - Robbert J de Haas
- Department of Radiology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Jeroen Hagendoorn
- Department of Surgery, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | | | - Ignace H de Hingh
- Department of Surgery, Catharina Hospital, Eindhoven and GROW-School for Oncology and Developmental Biology, Maastricht University, Maastricht, Netherlands
| | - Geert Kazemier
- Department of Surgery, Cancer Centre Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Marion van der Kolk
- Department of Surgery, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Mike Liem
- Department of Surgery, Medisch Spectrum Twente, Enschede, Netherlands
| | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, Netherlands
| | - Misha D Luyer
- Department of Surgery, Catharina Hospital, Eindhoven and GROW-School for Oncology and Developmental Biology, Maastricht University, Maastricht, Netherlands
| | - Vincent E de Meijer
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - J Sven Mieog
- Department of Surgery, Leiden University Medical Centre, Leiden, Netherlands
| | | | | | - Wouter W Te Riele
- Department of Surgery, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | - Daphne Roos
- Department of Surgery, Reinier de Graaf Hospital, Delft, Netherlands
| | | | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Fennie Wit
- Department of Surgery, Tjongerschans Hospital, Heerenveen, Netherlands
| | - Babs A Zonderhuis
- Department of Surgery, Cancer Centre Amsterdam, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Lois A Daamen
- Department of Surgery, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | - C Henri van Werkhoven
- Julius Centre for Health Sciences and Primary Care, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | - I Quintus Molenaar
- Department of Surgery, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Centre Utrecht, St Antonius Hospital, Nieuwegein and University Medical Centre Utrecht, Utrecht, Netherlands.
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24
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Leoni J, Rougemont AL, Calinescu AM, Ansari M, Compagnon P, Wilde JCH, Wildhaber BE. Effect of Centralization on Surgical Outcome of Children Operated for Liver Tumors in Switzerland: A Retrospective Comparative Study. CHILDREN 2022; 9:children9020217. [PMID: 35204937 PMCID: PMC8870146 DOI: 10.3390/children9020217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 01/18/2022] [Accepted: 02/01/2022] [Indexed: 11/27/2022]
Abstract
Background: Pediatric liver surgery is complex, and complications are not uncommon. Centralization of highly specialized surgery has been shown to improve quality of care. In 2012, pediatric liver surgery was centralized in Switzerland in one national center. This study analyses results before and after centralization. Methods: Retrospective monocentric comparative study. Analysis of medical records of children (0–16 years) operated for any liver tumor between 1 January 2001 and 31 December 2020. Forty-one patients were included: 14 before centralization (before 1 January 2012) and 27 after centralization (after 1 January 2012). Epidemiological, pre-, intra-, and post-operative data were collected. Fischer’s exact and t-test were used to compare groups. Results: The two cohorts were homogeneous. Operating time was reduced, although not significantly, from 366 to 277 min. Length of postoperative stay and mortality were not statistically different between groups. Yet, after centralization, overall postoperative complication rate decreased significantly from 57% to 15% (p = 0.01), Clavien > III complications decreased from 50% to 7% (p < 0.01), and hepatic recurrences were also significantly reduced (40% to 5%, p = 0.03). Conclusion: Centralization of the surgical management of liver tumors in Switzerland has improved quality of care in our center by significantly reducing postoperative complications and hepatic recurrence.
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Affiliation(s)
- Jasmine Leoni
- Swiss Pediatric Liver Center, Geneva University Hospitals, 1205 Geneva, Switzerland; (J.L.); (A.-L.R.); (A.M.C.); (M.A.); (P.C.); (J.C.H.W.)
- Division of Child and Adolescent Surgery, Department of Women, Child and Adolescent, Geneva University Hospitals, 1205 Geneva, Switzerland
- Department of Pediatrics, Gynecology and Obstetrics, University of Geneva, 1205 Geneva, Switzerland
| | - Anne-Laure Rougemont
- Swiss Pediatric Liver Center, Geneva University Hospitals, 1205 Geneva, Switzerland; (J.L.); (A.-L.R.); (A.M.C.); (M.A.); (P.C.); (J.C.H.W.)
- Diagnostic Department, Division of Clinical Pathology, Swiss Pediatric Liver Center, Geneva University Hospitals, 1205 Geneva, Switzerland
| | - Ana M. Calinescu
- Swiss Pediatric Liver Center, Geneva University Hospitals, 1205 Geneva, Switzerland; (J.L.); (A.-L.R.); (A.M.C.); (M.A.); (P.C.); (J.C.H.W.)
- Division of Child and Adolescent Surgery, Department of Women, Child and Adolescent, Geneva University Hospitals, 1205 Geneva, Switzerland
- Department of Pediatrics, Gynecology and Obstetrics, University of Geneva, 1205 Geneva, Switzerland
| | - Marc Ansari
- Swiss Pediatric Liver Center, Geneva University Hospitals, 1205 Geneva, Switzerland; (J.L.); (A.-L.R.); (A.M.C.); (M.A.); (P.C.); (J.C.H.W.)
- Department of Pediatrics, Gynecology and Obstetrics, University of Geneva, 1205 Geneva, Switzerland
- Unit of Oncology and Haematology, Department of Women, Child and Adolescent, Geneva University Hospitals and CANSEARCH Research Platform in Pediatric Oncology and Hematology, 1205 Geneva, Switzerland
| | - Philippe Compagnon
- Swiss Pediatric Liver Center, Geneva University Hospitals, 1205 Geneva, Switzerland; (J.L.); (A.-L.R.); (A.M.C.); (M.A.); (P.C.); (J.C.H.W.)
- Department of Surgery, Division of Transplantation, University Hospitals of Geneva, 1205 Geneva, Switzerland
| | - Jim C. H. Wilde
- Swiss Pediatric Liver Center, Geneva University Hospitals, 1205 Geneva, Switzerland; (J.L.); (A.-L.R.); (A.M.C.); (M.A.); (P.C.); (J.C.H.W.)
- Division of Child and Adolescent Surgery, Department of Women, Child and Adolescent, Geneva University Hospitals, 1205 Geneva, Switzerland
- Department of Pediatrics, Gynecology and Obstetrics, University of Geneva, 1205 Geneva, Switzerland
| | - Barbara E. Wildhaber
- Swiss Pediatric Liver Center, Geneva University Hospitals, 1205 Geneva, Switzerland; (J.L.); (A.-L.R.); (A.M.C.); (M.A.); (P.C.); (J.C.H.W.)
- Division of Child and Adolescent Surgery, Department of Women, Child and Adolescent, Geneva University Hospitals, 1205 Geneva, Switzerland
- Department of Pediatrics, Gynecology and Obstetrics, University of Geneva, 1205 Geneva, Switzerland
- Correspondence:
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25
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Hospital volume-outcome relationship in total knee arthroplasty: a systematic review and dose-response meta-analysis. Knee Surg Sports Traumatol Arthrosc 2022; 30:2862-2877. [PMID: 34494124 PMCID: PMC9309153 DOI: 10.1007/s00167-021-06692-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 08/06/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE This systematic review and dose-response meta-analysis aimed to investigate the relationship between hospital volume and outcomes for total knee arthroplasty (TKA). METHODS MEDLINE, Embase, CENTRAL and CINAHL were searched up to February 2020 for randomised controlled trials and cohort studies that reported TKA performed in hospitals with at least two different volumes and any associated patient-relevant outcomes. The adjusted effect estimates (odds ratios, OR) were pooled using a random-effects, linear dose-response meta-analysis. Heterogeneity was quantified using the I2-statistic. ROBINS-I and the GRADE approach were used to assess the risk of bias and the confidence in the cumulative evidence, respectively. RESULTS A total of 68 cohort studies with data from 1985 to 2018 were included. The risk of bias for all outcomes ranged from moderate to critical. Higher hospital volume may be associated with a lower rate of early revision ≤ 12 months (narrative synthesis of k = 7 studies, n = 301,378 patients) and is likely associated with lower mortality ≤ 3 months (OR = 0.91 per additional 50 TKAs/year, 95% confidence interval [0.87-0.95], k = 9, n = 2,638,996, I2 = 51%) and readmissions ≤ 3 months (OR = 0.98 [0.97-0.99], k = 3, n = 830,381, I2 = 44%). Hospital volume may not be associated with the rates of deep infections within 1-4 years, late revision (1-10 years) or adverse events ≤ 3 months. The confidence in the cumulative evidence was moderate for mortality and readmission rates; low for early revision rates; and very low for deep infection, late revision and adverse event rates. CONCLUSION An inverse volume-outcome relationship probably exists for some TKA outcomes, including mortality and readmissions, and may exist for early revisions. Small reductions in unfavourable outcomes may be clinically relevant at the population level, supporting centralisation of TKA to high-volume hospitals. LEVEL OF EVIDENCE III. REGISTRATION NUMBER The study was registered in the International Prospective Register of Systematic Reviews (PROSPERO CRD42019131209 available at: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=131209 ).
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Acher AW, Weber SM, Pawlik TM. Does the Volume-Outcome Association in Pancreas Cancer Surgery Justify Regionalization of Care? A Review of Current Controversies. Ann Surg Oncol 2021; 29:1257-1268. [PMID: 34522998 DOI: 10.1245/s10434-021-10765-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 08/15/2021] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Increasing hospital or surgeon volume is associated with improved outcomes among patients with pancreatic cancer. Promotion of regionalized care is based on this volume-outcome association. However, other research has exposed nuances and complexities inherent to this association that should be considered when promoting regionalized care models. We herein provide a critical review of the literature on the volume-outcome association and a discussion of areas of ongoing controversy. METHODS A PubMed literature search was conducted for the years 1995-2020. Peer reviewed original research studies were selected for critical review based on study design, potential to draw meaningful conclusions from the data, and discussion of current knowledge gaps. RESULTS Based on the cumulative published literature, hospital/surgeon volume and patient mortality are inversely related. However, it remains unclear whether volume is a proxy for other more causative variables inherent in high-volume centers. Interpretation of the volume-outcome association is made more difficult to interpret due to the large variation in the definition of high volume, difficulty in isolating the individual impact of surgeon versus hospital volume, challenges in quantifying health system processes related to volume, and the fact that some low-volume centers consistently achieve excellent clinical results. Implementation of true regionalized care models has been rare, likely reflecting both health system and patient level challenges. CONCLUSION The volume-outcome association has been consistently demonstrated to be important to the care of patients with pancreas cancer. The underlying mechanism of this association to explain the overall benefit is likely multifactorial. Better understanding of what drives the volume-outcome association may increase access to optimized care for a broader range of hospital systems and patients.
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Affiliation(s)
- Alexandra W Acher
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Sharon M Weber
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Timothy M Pawlik
- Department of Surgery, The Ohio State University College of Medicine, The James Comprehensive Cancer Center, Columbus, OH, USA.
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Lequeu JB, Cottenet J, Facy O, Perrin T, Bernard A, Quantin C. Failure to rescue in patients with distal pancreatectomy: a nationwide analysis of 10,632 patients. HPB (Oxford) 2021; 23:1410-1417. [PMID: 33622649 DOI: 10.1016/j.hpb.2021.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 02/01/2021] [Accepted: 02/02/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND FTR appears as a major cause of postoperative mortality (POM). Hospital volume has an impact on FTR in pancreatic surgery but no study has investigated this relationship more specifically in DP. METHODS We analysed patients with DP between 2009 and 2018 through a nationwide database. FTR definition was mortality among patients who experiment major complications. The cutoff between high and low volume centers was 20 pancreatectomies per year. RESULTS Some 10,632 patients underwent DP, 5048 (47.5%) were operated in 602 (95.4%) low volume centers and 5584 (52.5%) in 29 (4.6%) high volume centers. Overall FTR occurred in 11.2% of patients and was significantly reduced in high volume centers compared to low volume centers (10.2% vs 12.5%, p = 0.047). In multivariate analysis, surgery in a high volume center was a protective factor for POM (OR = 0.570, CI95% [0.505-0.643], p < 0.001) and also for FTR (OR = 0.550, CI95% [0.486-0.630], p < 0.001). CONCLUSION Hospital volume has a positive impact on FTR in DP. Patients with higher risk of FTR are men, with high modified Charlson comorbidity index, malignant conditions and open procedures.
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Affiliation(s)
- Jean-Baptiste Lequeu
- Dijon University Hospital, Department of Digestive Surgical Oncology, Dijon F-21000, France.
| | - Jonathan Cottenet
- Dijon University Hospital, Clinical Epidemiology/Clinical Trials Unit, Clinical Investigation Center, Dijon F-21000, France
| | - Olivier Facy
- Dijon University Hospital, Department of Digestive Surgical Oncology, Dijon F-21000, France
| | - Thomas Perrin
- Dijon University Hospital, Department of Digestive Surgical Oncology, Dijon F-21000, France
| | - Alain Bernard
- Dijon University Hospital, Department of Thoracic Surgery, Dijon F-21000, France
| | - Catherine Quantin
- Dijon University Hospital, Clinical Epidemiology/Clinical Trials Unit, Clinical Investigation Center, Dijon F-21000, France
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Blacker S, Lahiri RP, Phillips M, Pinn G, Pencavel TD, Kumar R, Riga AT, Worthington TR, Karanjia ND, Frampton AE. Which patients benefit from preoperative biliary drainage in resectable pancreatic cancer? Expert Rev Gastroenterol Hepatol 2021; 15:855-863. [PMID: 34036856 DOI: 10.1080/17474124.2021.1915127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Recent studies have indicated that preoperative biliary drainage (PBD) should not be routinely performed in all patients suffering from obstructive jaundice before pancreatic surgery. The severity of jaundice that mandates PBD has yet to be defined. The evaluated paper examines the impact of PBD on intra-operative, and post-operative outcomes in patients initially presenting with severe obstructive jaundice (bilirubin ≥250 μmol/L). In this key paper evaluation, the impact of PBD versus a direct surgery (DS) approach is discussed. The arguments for and against each approach are considered with regards to drainage associated morbidity and mortality, resection rates, survival and the impact of chemotherapy and malnutrition. Concentrating on resectable head of pancreas tumors, this mini-review aims to scrutinize the authors' recommendations, alongside those of prominent papers in the field.
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Affiliation(s)
- Sarah Blacker
- HPB Surgical Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK
| | - Rajiv P Lahiri
- HPB Surgical Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK
| | - Mary Phillips
- Dept. Of Nutrition and Dietetics, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK
| | - Graham Pinn
- HPB Surgical Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK
| | - Tim D Pencavel
- HPB Surgical Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK
| | - Rajesh Kumar
- HPB Surgical Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK
| | - Angela T Riga
- HPB Surgical Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK
| | - Tim R Worthington
- HPB Surgical Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK
| | - Nariman D Karanjia
- HPB Surgical Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK
| | - Adam E Frampton
- HPB Surgical Unit, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK.,Dept. Of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, the Leggett Building, University of Surrey, Guildford, Surrey, UK
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Management of Patients with Pancreatic Ductal Adenocarcinoma in the Real-Life Setting: Lessons from the French National Hospital Database. Cancers (Basel) 2021; 13:cancers13143515. [PMID: 34298729 PMCID: PMC8306072 DOI: 10.3390/cancers13143515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 07/09/2021] [Accepted: 07/10/2021] [Indexed: 02/06/2023] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) remains a major public health challenge, and faces disparities and delays in the diagnosis and access to care. Our purposes were to describe the medical path of PDAC patients in the real-life setting and evaluate the overall survival at 1 year. We used the national hospital discharge summaries database system to analyze the management of patients with newly diagnosed PDAC over the year 2016 in Auvergne-Rhône-Alpes region (AuRA) (France). A total of 1872 patients met inclusion criteria corresponding to an incidence of 22.6 per 100,000 person-year. Within the follow-up period, 353 (18.9%) were operated with a curative intent, 743 (39.7%) underwent chemo- and/or radiotherapy, and 776 (41.4%) did not receive any of these treatments. Less than half of patients were operated in a high-volume center, defined by more than 20 PDAC resections performed annually, mainly university hospitals. The 1-year survival rate was 47% in the overall population. This study highlights that a significant number of patients with PDAC are still operated in low-volume centers or do not receive any specific oncological treatment. A detailed analysis of the medical pathways is necessary in order to identify the medical and territorial determinants and their impact on the patient's outcome.
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Abstract
OBJECTIVE This analysis aimed to compare failure to rescue (FTR) after pancreatoduodenectomy across the Atlantic. SUMMARY BACKGROUND DATA FTR, or mortality after development of a major complication, is a quality metric originally created to compare hospital results. FTR has been studied in North American and Northern European patients undergoing pancreatoduodenectomy (PD). However, a direct comparison of FTR after PD between North America and Northern Europe has not been performed. METHODS Patients who underwent PD in North America, the Netherlands, Sweden and Germany (GAPASURG dataset) were identified from their respective registries (2014-17). Patients who developed a major complication defined as Clavien-Dindo ≥3 or developed a grade B/C postoperative pancreatic fistula (POPF) were included. Preoperative, intraoperative, and postoperative variables were compared between patients with and without FTR. Variables significant on univariable analysis were entered into a logistic regression for FTR. RESULTS Major complications occurred in 6188 of 22,983 patients (26.9%) after PD, and 504 (8.1%) patients had FTR. North American and Northern European patients with complications differed, and rates of FTR were lower in North America (5.4% vs 12%, P < 0.001). Fourteen factors from univariable analysis contributing to differences in patients who developed FTR were included in a logistic regression. On multivariable analysis, factors independently associated with FTR were age, American Society of Anesthesiology ≥3, Northern Europe, POPF, organ failure, life-threatening complication, nonradiologic intervention, and reoperation. CONCLUSIONS Older patients with severe systemic diseases are more difficult to rescue. Failure to rescue is more common in Northern Europe than North America. In stable patients, management of complications by interventional radiology is preferred over reoperation.
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Hopstaken JS, van Dalen D, van der Kolk BM, van Geenen EJM, Hermans JJ, Gootjes EC, Schers HJ, van Dulmen AM, van Laarhoven CJHM, Stommel MWJ. Continuity of care experienced by patients in a multi-institutional pancreatic care network: a pilot study. BMC Health Serv Res 2021; 21:416. [PMID: 33941181 PMCID: PMC8094517 DOI: 10.1186/s12913-021-06431-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 04/16/2021] [Indexed: 11/10/2022] Open
Abstract
Background Over the past decades, health care services for pancreatic surgery were reorganized. Volume norms were applied with the result that only a limited number of expert centers perform pancreatic surgery. As a result of this centralization of pancreatic surgery, the patient journey of patients with pancreatic tumors has become multi-institutional. To illustrate, patients are referred to a center of expertise for pancreatic surgery whereas other parts of pancreatic care, such as chemotherapy, take place in local hospitals. This fragmentation of health care services could affect continuity of care (COC). The aim of this study was to assess COC perceived by patients in a pancreatic care network and investigate correlations with patient-and care-related characteristics. Methods This is a pilot study in which patients with (pre) malignant pancreatic tumors discussed in a multidisciplinary tumor board in a Dutch tertiary hospital were asked to participate. Patients were asked to fill out the Nijmegen Continuity of Care-questionnaire (NCQ) (5-point Likert scale). Additionally, their patient-and care-related data were retrieved from medical records. Correlations of NCQ score and patient-and care-related characteristics were calculated with Spearman’s correlation coefficient. Results In total, 44 patients were included (92% response rate). Pancreatic cancer was the predominant diagnosis (32%). Forty percent received a repetition of diagnostic investigations in the tertiary hospital. Mean scores for personal continuity were 3.55 ± 0.74 for GP, 3.29 ± 0.91 for the specialist and 3.43 ± 0.65 for collaboration between GPs and specialists. Overall COC was scored with a mean 3.38 ± 0.72. No significant correlations were observed between NCQ score and certain patient-or care-related characteristics. Conclusion Continuity of care perceived by patients with pancreatic tumors was scored as moderate. This outcome supports the need to improve continuity of care within multi-institutional pancreatic care networks. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06431-2.
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Affiliation(s)
- J S Hopstaken
- Department of Surgery, Radboud university medical center, Geert Grooteplein 10 (route 618), 6525 GA, Nijmegen, the Netherlands.,Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, the Netherlands
| | - D van Dalen
- Department of Surgery, Radboud university medical center, Geert Grooteplein 10 (route 618), 6525 GA, Nijmegen, the Netherlands
| | - B M van der Kolk
- Department of Surgery, Radboud university medical center, Geert Grooteplein 10 (route 618), 6525 GA, Nijmegen, the Netherlands
| | - E J M van Geenen
- Department of Gastroenterology, Radboud university medical center, Nijmegen, the Netherlands
| | - J J Hermans
- Department of Medical Imaging, Radboud university medical center, Nijmegen, the Netherlands
| | - E C Gootjes
- Department of Medical Oncology, Radboud university medical center, Nijmegen, the Netherlands
| | - H J Schers
- Department of Primary and Community Care, Radboud university medical center, Nijmegen, the Netherlands
| | - A M van Dulmen
- Department of Primary and Community Care, Radboud university medical center, Nijmegen, the Netherlands.,Nivel (Netherlands institute for health services research), Utrecht, the Netherlands
| | - C J H M van Laarhoven
- Department of Surgery, Radboud university medical center, Geert Grooteplein 10 (route 618), 6525 GA, Nijmegen, the Netherlands
| | - M W J Stommel
- Department of Surgery, Radboud university medical center, Geert Grooteplein 10 (route 618), 6525 GA, Nijmegen, the Netherlands.
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Partelli S, Sclafani F, Barbu ST, Beishon M, Bonomo P, Braz G, de Braud F, Brunner T, Cavestro GM, Crul M, Trill MD, Ferollà P, Herrmann K, Karamitopoulou E, Neuzillet C, Orsi F, Seppänen H, Torchio M, Valenti D, Zamboni G, Zins M, Costa A, Poortmans P. European Cancer Organisation Essential Requirements for Quality Cancer Care (ERQCC): Pancreatic Cancer. Cancer Treat Rev 2021; 99:102208. [PMID: 34238640 DOI: 10.1016/j.ctrv.2021.102208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 04/07/2021] [Accepted: 04/09/2021] [Indexed: 12/14/2022]
Abstract
European Cancer Organisation Essential Requirements for Quality Cancer Care (ERQCC) are written by experts representing all disciplines involved in cancer care in Europe. They give patients, health professionals, managers and policymakers a guide to essential care throughout the patient journey. Pancreatic cancer is an increasing cause of cancer mortality and has wide variation in treatment and care in Europe. It is a major healthcare burden and has complex diagnosis and treatment challenges. Care must be carried out only in pancreatic cancer units or centres that have a core multidisciplinary team (MDT) and an extended team of health professionals detailed here. Such units are far from universal in European countries. To meet European aspirations for comprehensive cancer control, healthcare organisations must consider the requirements in this paper, paying particular attention to multidisciplinarity and patient-centred pathways from diagnosis, to treatment, to survivorship.
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Affiliation(s)
- Stefano Partelli
- European Society of Surgical Oncology (ESSO); IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Sclafani
- European Organisation for Research and Treatment of Cancer (EORTC); Institut Jules Bordet, Brussels, Belgium
| | - Sorin Traian Barbu
- Pancreatic Cancer Europe (PCE); Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Marc Beishon
- Cancer World, European School of Oncology (ESO), Milan, Italy
| | - Pierluigi Bonomo
- Flims Alumni Club (FAC); Careggi University Hospital, Florence, Italy
| | - Graça Braz
- European Oncology Nursing Society (EONS); Portuguese Oncology Institute, Porto, Portugal
| | - Filippo de Braud
- Organisation of European Cancer Institutes (OECI); IRCCS Foundation National Cancer Institute of Milan, Milan, Italy
| | - Thomas Brunner
- European Society for Radiotherapy and Oncology (ESTRO); Otto von Guericke University, Magdeburg, Germany
| | - Giulia Martina Cavestro
- European Hereditary Tumour Group (EHTG); IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Mirjam Crul
- European Society of Oncology Pharmacy (ESOP); Amsterdam University Medical Centre, Netherlands
| | - Maria Die Trill
- International Psycho-Oncology Society (IPOS); ATRIUM: Psycho-Oncology & Clinical Psychology, Madrid, Spain
| | - Piero Ferollà
- International Neuroendocrine Cancer Alliance (INCA); Umbria Regional Cancer Network, Perugia, Italy
| | - Ken Herrmann
- European Association of Nuclear Medicine (EANM); University Hospital Essen, Essen, Germany
| | - Eva Karamitopoulou
- European Society of Pathology (ESP); Institute of Pathology, University of Bern, Bern, Switzerland
| | - Cindy Neuzillet
- International Society of Geriatric Oncology (SIOG), Institut Curie, Saint-Cloud, France
| | - Franco Orsi
- Cardiovascular and Interventional Radiological Society of Europe (CIRSE); European Institute of Oncology, Milan, Italy
| | - Hanna Seppänen
- Association of European Cancer Leagues (ECL); Helsinki University Hospital, Helsinki, Finland
| | - Martina Torchio
- Organisation of European Cancer Institutes (OECI); IRCCS Foundation National Cancer Institute of Milan, Milan, Italy
| | - Danila Valenti
- European Association for Palliative Care (EAPC); Palliative Care Network, AUSL Bologna, Bologna, Italy
| | - Giulia Zamboni
- European Society of Oncologic Imaging (ESOI); University Hospital Verona, Verona, Italy
| | - Marc Zins
- European Society of Radiology (ESR); Groupe hospitalier Paris Saint-Joseph, Paris, France
| | | | - Philip Poortmans
- European Cancer Organisation (ECCO); Iridium Kankernetwerk and University of Antwerp, Wilrijk-Antwerp, Belgium
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Groen JV, Douwes TA, van Eycken E, van der Geest LGM, Johannesen TB, Besselink MG, Koerkamp BG, Wilmink JW, Bonsing BA, Portielje JEA, van de Velde CJH, Bastiaannet E, Mieog JSD. Treatment and Survival of Elderly Patients with Stage I-II Pancreatic Cancer: A Report of the EURECCA Pancreas Consortium. Ann Surg Oncol 2020; 27:5337-5346. [PMID: 32388741 PMCID: PMC7669775 DOI: 10.1245/s10434-020-08539-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Elderly patients with pancreatic cancer are underrepresented in clinical trials, resulting in a lack of evidence. OBJECTIVE The aim of this study was to compare treatment and overall survival (OS) of patients aged ≥ 70 years with stage I-II pancreatic cancer in the EURECCA Pancreas Consortium. METHODS This was an observational cohort study of the Belgian (BE), Dutch (NL), and Norwegian (NOR) cancer registries. The primary outcome was OS, while secondary outcomes were resection, 90-day mortality after resection, and (neo)adjuvant and palliative chemotherapy. RESULTS In total, 3624 patients were included. Resection (BE: 50.2%; NL: 36.2%; NOR: 41.3%; p < 0.001), use of (neo)adjuvant chemotherapy (BE: 55.9%; NL: 41.9%; NOR: 13.8%; p < 0.001), palliative chemotherapy (BE: 39.5%; NL: 6.0%; NOR: 15.7%; p < 0.001), and 90-day mortality differed (BE: 11.7%; NL: 8.0%; NOR: 5.2%; p < 0.001). Furthermore, median OS in patients with (BE: 17.4; NL: 15.9; NOR: 25.4 months; p < 0.001) and without resection (BE: 7.0; NL: 3.9; NOR: 6.5 months; p < 0.001) also differed. CONCLUSIONS Differences were observed in treatment and OS in patients aged ≥ 70 years with stage I-II pancreatic cancer, between the population-based cancer registries. Future studies should focus on selection criteria for (non)surgical treatment in older patients so that clinicians can tailor treatment.
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Affiliation(s)
- Jesse V Groen
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands.
| | - Tom A Douwes
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | | | - Lydia G M van der Geest
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
| | - Tom B Johannesen
- Registry Department, The Cancer Registry of Norway, Oslo, Norway
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam Amsterdam, UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Johanna W Wilmink
- Department of Medical Oncology, Cancer Center Amsterdam, UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Bert A Bonsing
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Johanna E A Portielje
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Cornelus J H van de Velde
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Esther Bastiaannet
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
- Department of Medical Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
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Outcome Quality Beyond the Mean - An Analysis of 43,231 Pancreatic Surgical Procedures Related to Hospital Volume. Ann Surg 2020; 276:159-166. [PMID: 33234781 DOI: 10.1097/sla.0000000000004315] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to examine whether elevated in-hospital mortality rates in lower volume hospitals are only valid on average or also apply for individual hospitals. SUMMARY OF BACKGROUND DATA Various studies demonstrated a volume-outcome relationship in pancreatic surgery with increased mortality in low volume hospitals. However, almost all studies assessed quality indicators only for groups of hospitals by averaged measures, neglecting variability of hospital performance. METHODS The German nationwide hospital discharge data (diagnosis-related groups-statistics) was used to determine risk-adjusted in-hospital mortality for all distal pancreatectomies (DP), pancreatoduodenectomies (Whipple-procedure, PD), and pylorus-preserving pancreatoduodenectomies (PPD) performed between 2011 and 2015. Hospitals were stratified according to annual and 5-year total procedure volume and examined in relation to average in-hospital mortality of the highest volume quintile. RESULTS Lowest adjusted mortality rates were observed in highest volume quintiles for each pancreatic resection procedure, with 6.2% for DP, 8.3% for PD, and 5.7% for PPD in the 5-year observation period. With these mortality rates as reference values the analysis revealed that a non-negligible proportion of hospitals performed equal or better (DP: 430/784, 54.5%; PD: 269/611, 44.0%; PPD: 255/565, 45.1%) than the hospitals of the highest volume quintile. CONCLUSIONS High quality of care, with in-hospital mortality rates less or equal to high-volume hospitals, is also achieved in hospitals with lesser procedure volume. Therefore, mere volume seems not suitable as proximal measure for assessing individual hospital quality. Instead, more sophisticated certification systems, that allow accurate quality assessment and better reflect clinical variability, should preferred to fixed minimum volume thresholds.
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Siegel J, Engelhardt KE, Hornor MA, Morgan KA, Lancaster WP. Travel distance and its interaction with patient and hospital factors in pancreas cancer care. Am J Surg 2020; 221:819-825. [PMID: 32891396 DOI: 10.1016/j.amjsurg.2020.08.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 07/24/2020] [Accepted: 08/21/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Although volume-outcome literature supports regionalization for complex procedures, travel may be burdensome. We assessed the relationship between overall survival and travel distance for patients undergoing pancreatic resection for adenocarcinoma. METHODS We analyzed the Fall 2018 National Cancer Database Public Use File. We defined distance traveled as a categorical variable (<12.5 miles, 12.5-50mi, and >50mi). We analyzed overall survival (OS) as a function of distance traveled using the log rank test and Cox proportional hazards models; we estimated stratified models to assess for interaction between distance and other relevant covariates. RESULTS In adjusted analysis of 39,089 patients, greater distance was associated with decreased OS (p = 0.0029). We found interactions between distance and center type, comorbidities, and age. Distance traveled was a negative factor for patients treated at low-volume academic centers (but not high-volume academic or non-academic centers). Additionally, distance traveled was a negative factor for OS in young, healthy patients but not geriatric, ill patients. CONCLUSION Traveling more than 12.5 miles for pancreatic resection was associated with worse OS. Prior to regionalization, evaluation of local resources may be necessary.
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Affiliation(s)
- Julie Siegel
- Department of Surgery, Medical University of South Carolina, 29 Jonathan Lucas St, Charleston, SC 29403, USA
| | - Kathryn E Engelhardt
- Department of Surgery, Medical University of South Carolina, 29 Jonathan Lucas St, Charleston, SC 29403, USA; Department of Surgery, Washington University in St. Louis, 1 Barnes Jewish Hospital Plaza, St. Louis, MO 63110, USA
| | - Melissa A Hornor
- Department of Surgery, Ohio State University, 410 W 10th Ave, Columbus, OH 43210, USA; Department of Surgery, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104, USA
| | - Katherine A Morgan
- Department of Surgery, Medical University of South Carolina, 29 Jonathan Lucas St, Charleston, SC 29403, USA
| | - William P Lancaster
- Department of Surgery, Medical University of South Carolina, 29 Jonathan Lucas St, Charleston, SC 29403, USA.
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Weniger M, Miksch RC, Maisonneuve P, Werner J, D'Haese JG. Improvement of survival after surgical resection of pancreatic cancer independent of adjuvant chemotherapy in the past two decades – A meta-regression. Eur J Surg Oncol 2020; 46:1516-1523. [DOI: 10.1016/j.ejso.2020.02.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 01/30/2020] [Accepted: 02/14/2020] [Indexed: 02/07/2023] Open
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Balzano G, Guarneri G, Pecorelli N, Paiella S, Rancoita PMV, Bassi C, Falconi M. Modelling centralization of pancreatic surgery in a nationwide analysis. Br J Surg 2020; 107:1510-1519. [DOI: 10.1002/bjs.11716] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 02/26/2020] [Accepted: 04/29/2020] [Indexed: 12/31/2022]
Abstract
Abstract
Background
The benefits of centralization of pancreatic surgery have been documented, but policy differs between countries. This study aimed to model various centralization criteria for their effect on a nationwide cohort.
Methods
Data on all pancreatic resections performed between 2014 and 2016 were obtained from the Italian Ministry of Health. Mortality was assessed for different hospital volume categories and for each individual facility. Observed mortality and risk-standardized mortality rate (RSMR) were calculated. Various models of centralization were tested by applying volume criteria alone or in combination with mortality thresholds.
Results
A total of 395 hospitals performed 12 662 resections; 305 hospitals were in the very low-volume category (mean 2·6 resections per year). The nationwide mortality rate was 6·2 per cent, increasing progressively from 3·1 per cent in very high-volume to 10·6 per cent in very low-volume hospitals. For the purposes of centralization, applying a minimum volume threshold of at least ten resections per year would lead to selection of 92 facilities, with an overall mortality rate of 5·3 per cent. However, the mortality rate would exceed 5 per cent in 48 hospitals and be greater than 10 per cent in 17. If the minimum volume were 25 resections per year, the overall mortality rate would be 4·7 per cent in 38 facilities, but still over 5 per cent in 17 centres and more than 10 per cent in five. The combination of a volume requirement (at least 10 resections per year) with a mortality threshold (maximum RSMR 5 or 10 per cent) would allow exclusion of facilities with unacceptable results, yielding a lower overall mortality rate (2·7 per cent in 45 hospitals or 4·2 per cent in 76 respectively).
Conclusion
The best performance model for centralization involved a threshold for volume combined with a mortality threshold.
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Affiliation(s)
- G Balzano
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Centre, Vita-Salute San Raffaele University, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - G Guarneri
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Centre, Vita-Salute San Raffaele University, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - N Pecorelli
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Centre, Vita-Salute San Raffaele University, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - S Paiella
- General and Pancreatic Surgery Unit — Pancreas Institute, University of Verona, Verona, Italy
| | - P M V Rancoita
- University Centre for Statistics in the Biomedical Sciences, Vita-Salute San Raffaele University, Milan, Italy
| | - C Bassi
- General and Pancreatic Surgery Unit — Pancreas Institute, University of Verona, Verona, Italy
| | - M Falconi
- Division of Pancreatic Surgery, Pancreas Translational and Clinical Research Centre, Vita-Salute San Raffaele University, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
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Miksch RC, D'Haese JG, Werner J. Surgical Therapy of Chronic Alcoholic Pancreatitis: A Literature Review of Current Options. Visc Med 2020; 36:191-197. [PMID: 32775349 PMCID: PMC7383250 DOI: 10.1159/000508174] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 04/22/2020] [Indexed: 11/19/2022] Open
Abstract
Chronic pancreatitis (CP) is associated with alcohol abuse in 80% of cases. The primary treatment goals in CP are pain reduction and avoidance of pancreatitis-associated complications. CP should be treated in an interdisciplinary approach. A recent randomized clinical trial showed that early surgery compared with an endoscopy-first approach resulted in reduced pain levels. Surgical resections are, therefore, the most efficient treatment of pancreatitis-associated pain as well as other complications and should be performed early in the course of the disease. Since most of the patients pre-sent with chronic inflammation of the pancreatic head, pancreatic head resection is the most common treatment option. Duodenum-preserving pancreatic head resections are the surgical procedure of choice, but pancreaticoduodenectomies (Kausch-Whipple procedures) demonstrate similar outcome with regard to pain control, quality of life, and metabolic parameters. Other surgical procedures, including drainage procedures, pancreatic segmental resections, or left resections, are rarely indicated.
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Affiliation(s)
| | | | - Jens Werner
- Department of General, Visceral, and Transplantation Surgery, Ludwig Maximilian University Munich, Munich, Germany
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Søreide K, Nymo LS, Lassen K. Centralization of Pancreatic Surgery in Europe: an Update. J Gastrointest Surg 2019; 23:2322-2323. [PMID: 31485907 DOI: 10.1007/s11605-019-04383-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 08/27/2019] [Indexed: 01/31/2023]
Affiliation(s)
- Kjetil Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway. .,Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Linn S Nymo
- Department of Gastrointestinal Surgery, University Hospital of Northern Norway, Tromsø, Norway.,Institute of Clinical Medicine, The Arctic University of Norway, Tromsø, Norway
| | - Kristoffer Lassen
- Institute of Clinical Medicine, The Arctic University of Norway, Tromsø, Norway.,Department of Hepatobiliary and Pancreatic Surgery, Oslo University Hospital, Oslo, Norway
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Letter to Editor Reply to: "Centralization of Pancreatic Surgery in Europe: an Update". J Gastrointest Surg 2019; 23:2324-2325. [PMID: 31512102 DOI: 10.1007/s11605-019-04387-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 08/27/2019] [Indexed: 01/31/2023]
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