Benchmarking a new tertiary referral center for hepato-biliary surgery through a critical systematic review of available literature

Defining Benchmark Outcomes for Distal Pancreatectomy: Results of a French Multicentric Study

OBJECTIVE

Defining robust and standardized outcome references for distal pancreatectomy (DP) by using Benchmark analysis.

BACKGROUND

Outcomes after DP are recorded in medium or small-sized studies without standardized analysis. Therefore, the best results remain uncertain.

METHODS

This multicenter study included all patients undergoing DP for resectable benign or malignant tumors in 21 French expert centers in pancreas surgery from 2014 to 2018. A low-risk cohort defined by no significant comorbidities was analyzed to establish 18 outcome benchmarks for DP. These values were tested in high risk, minimally invasive and benign tumor cohorts.

RESULTS

A total of 1188 patients were identified and 749 low-risk patients were screened to establish Benchmark cut-offs. Therefore, Benchmark rate for mini-invasive approach was ≥36.8%. Benchmark cut-offs for postoperative mortality, major morbidity grade ≥3a and clinically significant pancreatic fistula rates were 0%, ≤27%, and ≤28%, respectively. The benchmark rate for readmission was ≤16%. For patients with pancreatic adenocarcinoma, cut-offs were ≥75%, ≥69.5%, and ≥66% for free resection margins (R0), 1-year disease-free survival and 3-year overall survival, respectively. The rate of mini-invasive approach in high-risk cohort was lower than the Benchmark cut-off (34.1% vs ≥36.8%). All Benchmark cut-offs were respected for benign tumor group. The proportion of benchmark cases was correlated to outcomes of DP. Centers with a majority of low-risk patients had worse results than those operating complex cases.

CONCLUSION

This large-scale study is the first benchmark analysis of DP outcomes and provides robust and standardized data. This may allow for comparisons between surgeons, centers, studies, and surgical techniques.

Variations in risk-adjusted outcomes following 4318 laparoscopic liver resections

Background/Purpose

Quality measures in surgery are important to establish appropriate levels of care and to develop improvement strategies. The purpose of this study was to provide risk‐adjusted outcome measures after laparoscopic liver resection (LLR).

Methods

Data from a prospective, multicenter database involving 4318 patients submitted to LLRs in 41 hospitals from an intention‐to‐treat approach (2014–2020) were used to analyze heterogeneity (I²) among centers and to develop a risk‐adjustment model on outcome measures through multivariable mixed‐effect models to account for confounding due to case‐mix.

Results

Involved hospitals operated on very different patients: the largest heterogeneity was observed for operating in the presence of previous abdominal surgery (I²:79.1%), in cirrhotic patients (I²:89.3%) suffering from hepatocellular carcinoma (I²:88.6%) or requiring associated intestinal resections (I²:82.8%) and in regard to technical complexity (I² for the most complex LLRs: 84.1%). These aspects determined substantial or large heterogeneity in overall morbidity (I²:84.9%), in prolonged in‐hospital stay (I²:86.9%) and in conversion rate (I²:73.4%). Major complication had medium heterogeneity (I²:46.5%). The heterogeneity of mortality was null. Risk‐adjustment accounted for all of this variability and the final risk‐standardized conversion rate was 8.9%, overall morbidity was 22.1%, major morbidity was 5.1% and prolonged in‐hospital stay was 26.0%. There were no outliers among the 41 participating centers. An online tool was provided.

Conclusions

A benchmark for LLRs including all eligible patients was provided, suggesting that surgeons can act accordingly in the interest of the patient, modifying their approach in relation to different indications and different experience, but finally providing the same quality of care.