Surgeon volume impacts hospital mortality for pancreatic resection

Extending Quality Improvement for Pancreatoduodenectomy Within the High-Volume Setting: The Experience Factor

OBJECTIVE

To analyze the association of a surgeon's experience with postoperative outcomes of pancreatoduodenectomies (PDs) when stratified by Fistula Risk Score (FRS).

BACKGROUND

Centralization is now well-established for pancreatic surgery. Nevertheless, the benefits of individual surgeon's experience in high-volume settings remain undefined.

METHODS

Pancreatoduodenectomies performed by 82 surgeons across 18 international specialty institutions (median: 140 PD/year) were analyzed. Surgeon cumulative PD volume was linked with postoperative outcomes through multivariable models, adjusted for patient/operative characteristics and the FRS. Then, surgeon experience was also stratified by the 10, previously defined, most clinically impactful scenarios for clinically relevant pancreatic fistula (CR-POPF) development.

RESULTS

Of 8189 PDs, 18.7% suffered severe complications (Accordion≥3), 4.8% were reoperated upon and 2.2% expired. Although the most experienced surgeons (top-quartile; >525 career PDs) more often operated on riskier cases, their experience was significantly associated with declines in CR-POPF ( P <0.001), severe complications ( P =0.008), reoperations ( P <0.001), and length of stay (LOS) ( P <0.001)-accentuated even more in the most impactful FRS scenarios (2830 patients). Risk-adjusted models indicate male sex, increasing age, ASA class, and FRS, but not surgeon experience, as being associated with severe complications, failure-to-rescue, and mortality. Instead, upper-echelon experience demonstrates significant reductions in CR-POPF (OR 0.66), reoperations (OR 0.64), and LOS (OR 0.65) in moderate-to-high fistula risk circumstances (FRS≥3, 68% of cases).

CONCLUSIONS

At specialty institutions, major morbidity, mortality, and failure-to-rescue are primarily associated with baseline patient characteristics, while cumulative surgical experience impacts pancreatic fistula occurrence and its attendant effects for most higher-risk pancreatoduodenectomies. These data also suggest an extended proficiency curve exists for this operation.

Centralization of Pancreaticoduodenectomy: A Systematic Review and Spline Regression Analysis to Recommend Minimum Volume for a Specialist Pancreas Service

OBJECTIVE

Through a systematic review and spline curve analysis, to better define the minimum volume threshold for hospitals to perform (pancreaticoduodenectomy) and the high-volume center.

BACKGROUND

The pancreaticoduodenectomy (PD) is a resource-intensive procedure, with high morbidity and long hospital stays resulting in centralization towards high-volume hospitals; the published definition of high volume remains variable.

MATERIALS AND METHODS

Following a systematic review of studies comparing PD outcomes across volume groups, semiparametric regression modeling of morbidity (%), mortality (%), length of stay (days), lymph node harvest (number of nodes), and cost ($USD) as continuous variables were performed and fitted as a smoothed function of splines. If this showed a nonlinear association, then a "zero-crossing" technique was used, which produced "first and second derivatives" to identify volume thresholds.

RESULTS

Our analysis of 33 cohort studies (198,377 patients) showed 55 PDs/year and 43 PDs/year were the threshold value required to achieve the lowest morbidity and highest lymph node harvest, with model estimated df 5.154 ( P <0.001) and 8.254 ( P <0.001), respectively. The threshold value for mortality was ~45 PDs/year (model 9.219 ( P <0.001)), with the lowest mortality value (the optimum value) at ~70 PDs/year (ie, a high-volume center). No significant association was observed for cost ( edf =2, P =0.989) and length of stay ( edf =2.04, P =0.099).

CONCLUSIONS

There is a significant benefit from the centralization of PD, with 55 PDs/year and 43 PDs/year as the threshold value required to achieve the lowest morbidity and highest lymph node harvest, respectively. To achieve mortality benefit, the minimum procedure threshold is 45 PDs/year, with the lowest and optimum mortality value (ie, a high-volume center) at approximately 70 PDs/year.

Disparities in Access to High-Volume Surgeons and Specialized Care

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.

Association of rurality, socioeconomic status, and race with pancreatic cancer surgical treatment and survival

BACKGROUND

Pancreatectomy is a necessary component of curative intent therapy for pancreatic cancer, and patients living in nonmetropolitan areas may face barriers to accessing timely surgical care. We evaluated the intersecting associations of rurality, socioeconomic status (SES), and race on treatment and outcomes of Medicare beneficiaries with pancreatic cancer.

METHODS

We conducted a retrospective cohort study, using fee-for-service Medicare claims of beneficiaries with incident pancreatic cancer (2016-2018). We categorized beneficiary place of residence as metropolitan, micropolitan, or rural. Measures of SES were Medicare-Medicaid dual eligibility and the Area Deprivation Index. Primary study outcomes were receipt of pancreatectomy and 1-year mortality. Exposure-outcome associations were assessed with competing risks and logistic regression.

RESULTS

We identified 45 915 beneficiaries with pancreatic cancer, including 78.4%, 10.9%, and 10.7% residing in metropolitan, micropolitan, and rural areas, respectively. In analyses adjusted for age, sex, comorbidity, and metastasis, residents of micropolitan and rural areas were less likely to undergo pancreatectomy (adjusted subdistribution hazard ratio = 0.88 for rural, 95% confidence interval [CI] = 0.81 to 0.95) and had higher 1-year mortality (adjusted odds ratio = 1.25 for rural, 95% CI = 1.17 to 1.33) compared with metropolitan residents. Adjustment for measures of SES attenuated the association of nonmetropolitan residence with mortality, and there was no statistically significant association of rurality with pancreatectomy after adjustment. Black beneficiaries had lower likelihood of pancreatectomy than White, non-Hispanic beneficiaries (subdistribution hazard ratio = 0.80, 95% CI = 0.72 to 0.89, adjusted for SES). One-year mortality in metropolitan areas was higher for Black beneficiaries (adjusted odds ratio = 1.15, 95% CI = 1.05 to 1.26).

CONCLUSIONS

Rurality, socioeconomic deprivation, and race have complex interrelationships and are associated with disparities in pancreatic cancer treatment and outcomes.

Developing surgical skill level classification model using visual metrics and a gradient boosting algorithm

Objective

Assessment of surgical skills is crucial for improving training standards and ensuring the quality of primary care. This study aimed to develop a gradient boosting classification model (GBM) to classify surgical expertise into inexperienced, competent, and experienced levels in robot-assisted surgery (RAS) using visual metrics.

Methods

Eye gaze data were recorded from 11 participants performing four subtasks; blunt dissection, retraction, cold dissection, and hot dissection using live pigs and the da Vinci robot. Eye gaze data were used to extract the visual metrics. One expert RAS surgeon evaluated each participant's performance and expertise level using the modified Global Evaluative Assessment of Robotic Skills (GEARS) assessment tool. The extracted visual metrics were used to classify surgical skill levels and to evaluate individual GEARS metrics. Analysis of Variance (ANOVA) was used to test the differences for each feature across skill levels.

Results

Classification accuracies for blunt dissection, retraction, cold dissection, and burn dissection were 95%, 96%, 96%, and 96%, respectively. The time to complete only the retraction was significantly different among the 3 skill levels (p-value = 0.04). Performance was significantly different for 3 categories of surgical skill level for all subtasks (p-values<0.01). The extracted visual metrics were strongly associated with GEARS metrics (R2>0.7 for GEARS metrics evaluation models).

Conclusions

Machine learning (ML) algorithms trained by visual metrics of RAS surgeons can classify surgical skill levels and evaluate GEARS measures. The time to complete a surgical subtask may not be considered a stand-alone factor for skill level assessment.

National Economic Conditions May Impact the Financial Barriers to Travel for Cancer Operations

Background

Better cancer-related outcomes are associated with physicians and hospitals with higher case volume. This serves as an incentive to refer patients requiring complex cancer operations to large referral centers, which may require increased travel for patients. However, barriers exist for patients to travel for cancer care, some of which may be aggravated or alleviated by factors relating to the health of the national economy. This impact may be reflected in variability of travel distances for cancer operations over time particularly for complex operation such as pancreatectomy and esophagectomy compared with less complex resections such as those for breast cancer or melanoma.

Methods

We obtained the estimated travel distance for patients undergoing operations for cancer of the pancreas, esophagus, skin (melanoma), and breast from the National Cancer Database from 2004 to 2017 and correlated them with economic factors obtained from public sources. We then examined the impact of unemployment rates, gas prices, and inflation on travel distances regarding disadvantaged groups. Correlations were measured by the (rank-based, nonparametric) Spearman's correlation coefficient, and the corresponding P value is obtained by the asymptotic distribution of the coefficient. A P value of 0.05 equates to an absolute correlation value of 0.532. To adjust for multiple tests, a more restrictive P value of 0.01 was also assessed, which equates to correlation coefficients of absolute value greater than 0.661.

Results

There were 4,222,380 cases in the dataset, of which 1,781,056 remained after exclusion. The economic factors that were associated most strongly with the distance patients traveled for all cancer operation types were the labor force participation rate, personal savings, consumer price index, and changes in gasoline prices. Inflation and rising gasoline prices were often inversely related with travel distance in lower-income and less well-educated regions and African American patients.

Conclusions

Several macroeconomic factors correlate with the travel distance for operations, suggesting that the economic health of the nation may aggravate or alleviate the financial barriers to travel for cancer operations. Financially disadvantaged groups may be particularly vulnerable to changes in gasoline prices and inflation. Organizations serving these populations may need to increase patient support services during times of economic hardship to avoid the exacerbation of health care disparities.

The relationship of hospital and surgeon volume indicators and post-operative outcomes in pancreatic surgery: a systematic literature review, meta-analysis and guidance for valid outcome assessment

BACKGROUND

Available evidence on the volume-outcome relationship after pancreatic surgery is limited due to the narrow focus of interventions, volume indicators and outcomes considered as well as due to methodological differences of the included studies. Therefore, we aim to evaluate the volume-outcome relationship following pancreatic surgery following strict study selection and quality criteria, to identify aspects of methodological variation and to define a set of key methodological indicators to consider when aiming for comparable and valid outcome assessment.

METHODS

Four electronic databases were searched to identify studies on the volume-outcome relationship in pancreatic surgery published between the years 2000-2018. Following a double-screening process, data extraction, quality appraisal, and subgroup analysis, results of included studies were stratified and pooled using random effects meta-analysis.

RESULTS

Consistent associations were found between high hospital volume and both postoperative mortality (OR 0.35, 95% CI: 0.29-0.44) and major complications (OR 0.87, 95% CI: 0.80-0.94). A significant decrease in the odds ratio was also found for high surgeon volume and postoperative mortality (OR 0.29, 95%CI: 0.22-0.37).

DISCUSSION

Our meta-analysis confirms a positive effect for both hospital and surgeon volume indicators for pancreatic surgery. Further harmonization (e.g. surgery types, volume cut-offs/definition, case-mix adjustment, reported outcomes) are recommended for future empirical studies.

Profiling of a novel circadian clock-related prognostic signature and its role in immune function and response to molecular targeted therapy in pancreatic cancer

BACKGROUND

Pancreatic ductal adenocarcinoma (PADA) represents a devastating type of pancreatic cancer with high mortality. Defining a prognostic gene signature that can stratify patients with different risk will benefit cancer treatment strategies.

METHODS

Gene expression profiles of PADA patients were acquired from the Cancer Genome Atlas and Gene Expression Omnibus, including GSE62452 and GSE28735. Differential expression analysis was carried out using the package edgeR in R. Intro-tumor immune infiltrates were quantified by six different computational algorithms XCELL, TIMER, QUANTISEQ, MCPCOUNTER, EPIC, and CIBERSORT. Biological processes were investigated based on R package "clusterProfiler".

RESULTS

13 genes (ARNTL2, BHLHE40, FBXL17, FBXL8, PPP1CB, RBM4B, ADRB1, CCAR2, CDK1, CSNK1D, KLF10, PSPC1, SIAH2) were eligible for the development of a prognostic gene signature. Performance of the prognostic gene signature was assessed in the discovery set (n = 210), validation set (n = 52), and two external data set (GSE62452, n = 65, and GSE28735, n = 84). Area under the curve (AUC) for predicting 3-year overall survival was 0.727, 0.732, 0.700, and 0.658 in the training set, the validation set, and the two test sets, respectively. KM curve revealed that the low-risk group had an improved prognosis than the high-risk group in all four datasets. PCA analysis demonstrated that the low-risk group was apparently separated from the high-risk group. CD8 T cell and B cell were significantly reduced in the high-risk group than in the low-risk group, while neutrophils were significantly augmented in the high-risk group than in the low-risk group. BMS-536924, Foretinib, Linsitinib, and Sabutoclax were more sensitive in the low-risk group, whereas Erlotinib was more effective in the high-risk group.

CONCLUSIONS

We successfully established and verified a novel circadian clock-related gene signature, which could stratify patients with different risk and be reflective of the therapeutic effect of molecular targeted therapy. Our findings could incorporate the pharmacological modulation of circadian clock into future therapeutic strategies.

A nationwide certification system to increase the safety of highly advanced hepatobiliary-pancreatic surgery

BACKGROUND

To ensure that highly advanced hepatobiliary-pancreatic surgery (HBPS) is performed safely, the Japanese Society of Hepato-Biliary-Pancreatic Surgery (JSHBPS) board certification system for expert surgeons established a safety committee to monitor surgical safety.

METHODS

We investigated postoperative mortality rates based on summary reports of numbers and outcomes of highly advanced HBPS submitted annually by the board-certified training institutions from 2012 to 2019. We also analyzed summary reports on mortality cases submitted by institutions with high 90-day post-HBPS mortality rates and recommended site visits and surveys as necessary.

RESULTS

Highly advanced HBPS was performed in 121 518 patients during the 8-year period. Thirty-day mortality rates from 2012 to 2019 were 0.92%, 0.8%, 0.61%, 0.63%, 0.70%, 0.59%, 0.48%, and 0.52%, respectively (P < .001). Ninety-day mortality rates were 2.1%, 1.82%, 1.62%, 1.28%, 1.46%, 1.22%, 1.19%, and 0.98%, respectively (P < .001). Summary reports were submitted by 20 hospitals between 2015 and 2019. Mortality rates before and after the start of report submission and audit were 5.72% and 2.79%, respectively (odds ratio 0.690, 95% confidence interval 0.487-0.977; P = .037).

CONCLUSIONS

Development of a system for designation of board-certified expert surgeons and safety management improved the mortality rate associated with highly advanced HBPS.

Whipple’s pancreaticoduodenectomy at a resource-poor, low-volume center in Trinidad and Tobago

BACKGROUND

Many authorities advocate for Whipple’s procedures to be performed in high-volume centers, but many patients in poor developing nations cannot access these centers. We sought to determine whether clinical outcomes were acceptable when Whipple’s procedures were performed in a low-volume, resource-poor setting in the West Indies.

AIM

To study outcomes of Whipple’s procedures in a pancreatic unit in the West Indies over an eight-year period from June 1, 2013 to June 30, 2021.

METHODS

This was a retrospective study of all patients undergoing Whipple’s procedures in a pancreatic unit in the West Indies over an eight-year period from June 1, 2013 to June 30, 2021.

RESULTS

This center performed an average of 11.25 procedures per annum. There were 72 patients in the final study population at a mean age of 60.2 years, with 52.7% having American Society of Anesthesiologists scores ≥ III and 54.1% with Eastern Cooperative Oncology Group scores ≥ 2. Open Whipple’s procedures were performed in 70 patients and laparoscopic assisted procedures in 2. Portal vein resection/reconstruction was performed in 19 (26.4%) patients. In patients undergoing open procedures there was 367 ± 54.1 min mean operating time, 1394 ± 656.8 mL mean blood loss, 5.24 ± 7.22 d mean intensive care unit stay and 15.1 ± 9.53 d hospitalization. Six (8.3%) patients experienced minor morbidity, 10 (14%) major morbidity and there were 4 (5.5%) deaths.

CONCLUSION

This paper adds to the growing body of evidence that volume alone should not be used as a marker of quality for patients requiring Whipple’s procedures. Low volume centers in resource poor nations can achieve good short-term outcomes. This is largely due to the process of continuous, adaptive learning by the entire hospital.

Whipple’s operation with a modified centralization concept: A model in low-volume Caribbean centers

Conventional data suggest that complex operations, such as a pancreaticoduodenectomy (PD), should be limited to high volume centers. However, this is not practical in small, resource-poor countries in the Caribbean. In these settings, patients have no option but to have their PDs performed locally at low volumes, occasionally by general surgeons. In this paper, we review the evolution of the concept of the high-volume center and discuss the feasibility of applying this concept to low and middle-income nations. Specifically, we discuss a modification of this concept that may be considered when incorporating PD into low-volume and resource-poor countries, such as those in the Caribbean. This paper has two parts. First, we performed a literature review evaluating studies published on outcomes after PD in high volume centers. The data in the Caribbean is then examined and we discuss the incorporation of this operation into resource-poor hospitals with modifications of the centralization concept. In the authors’ opinions, most patients who require PD in the Caribbean do not have realistic opportunities to have surgery in high-volume centers in developed countries. In these settings, their only options are to have their operations in the resource-poor, low-volume settings in the Caribbean. However, post-operative outcomes may be improved, despite low-volumes, if a modified centralization concept is encouraged.

Fourteen years of pancreatic surgery for malignancy among ACS-NSQIP centers: Trends in major morbidity and mortality

BACKGROUND

The American College of Surgeons National Surgical Quality Improvement Program was established to help participating hospitals track and report surgical complications with the goal of improving surgical care. We sought to determine whether this has led to improvements in surgical outcomes for pancreatic malignancies.

METHODS

Patients with pancreatic malignancies who underwent surgical resection were identified from the American College of Surgeons National Surgical Quality Improvement Program database (2006-2019). Thirty-day postoperative major morbidity and mortality were analyzed by year. Major morbidity included organ and deep surgical site infection, venous thromboembolism, cardiac event, pneumonia, acute renal failure, sepsis, and respiratory failure.

RESULTS

Of the 28,888 patients identified, 51% were male, the median age was 68, 74.3% underwent a pancreaticoduodenectomy, and 25.7% underwent a distal pancreatectomy. Among patients who underwent a pancreaticoduodenectomy, there was a significant increase in major morbidity (annual percent change 0.77, P = .012) driven by increases in organ space surgical site infection (annual percent change 3.52, P < .001) and venous thromboembolism (annual percent change 4.72, P = .005). However, there was a decrease in postoperative mortality (annual percent change -4.58, P = .001). For distal pancreatectomy patients, there was no change in rates of overall major morbidity (annual percent change -1.35, P = .08) or mortality (annual percent change -3.21, P = .25).

CONCLUSION

Although major morbidity and mortality have not significantly changed for distal pancreatectomy patients, mortality has steadily decreased for patients undergoing pancreaticoduodenectomy, despite an increase in major morbidity. Whether this trend reflects a change in patient selection, an increase in detection of postoperative morbidities and/or an improvement in mitigation of these morbidities warrants further study.

Mortality factors in pancreatic surgery: A systematic review. How important is the hospital volume?

BACKGROUND

How the extent of confounding adjustment impact (hospital) volume-outcome relationships in published studies on pancreatic cancer surgery is unknown.

METHODS

A systematic literature search was conducted for studies that investigated the relationship between volume and outcome using a risk adjustment procedure by querying the following databases: PubMed, Cochrane Central Register of Controlled Trials, Livivo, Medline and the International Clinical Trials Registry Platform (last query: 2020/09/16). Importance of risk-adjusting covariates were assessed by effect size (odds ratio, OR) and statistical significance. The impact of covariate adjustment on hospital (or surgeon) volume effects was analyzed by regression and meta-regression models.

RESULTS

We identified 87 studies (75 based on administrative data) with nearly 1 million patients undergoing pancreatic surgery that included in total 71 covariates for risk adjustment. Of these, 33 (47%) had statistically significant effects on short-term mortality and 23 (32%) did not, while for 15 (21%) factors neither effect size nor statistical significance were reported. The most important covariates for short term mortality were patient-specific factors. Concerning the covariates, single comorbidities (OR: 4.6, 95% CI: 3.3 to 6.3) had the strongest impact on mortality followed by hospital volume (OR: 2.9, 95% CI: 2.5 to 3.3) and the procedure (OR: 2.2, 95% CI: 1.9 to 2.5). Among the single comorbidities, coagulopathy (OR: 4.5, 95% CI: 2.8 to 7.2) and dementia (OR: 4.2, 95% CI: 2.2 to 8.0) had the strongest influence on mortality. The regression analysis showed a significant decrease hospital volume effect with an increasing number of covariates considered (OR: 0.06, 95% CI: 0.10 to -0.03, P < 0.001), while such a relationship was not observed for surgeon volume (P = 0.35).

CONCLUSIONS

This analysis demonstrated a significant inverse relationship between the extent of risk adjustment and the volume effect, suggesting the presence of unmeasured confounding and overestimation of volume effects. However, the conclusions are limited in that only the number of included covariates was considered, but not the effect size of the non-included covariates.

The Effect of Hospital Versus Surgeon Volume on Short-Term Patient Outcomes After Pancreaticoduodenectomy: a SEER-Medicare Analysis

BACKGROUND

The volume-outcome relationship has been well-established for pancreaticoduodenectomy (PD). It remains unclear if this is primarily driven by hospital volume or individual surgeon experience.

OBJECTIVE

This study aimed to determine the relationship of hospital and surgeon volume on short-term outcomes of patients with pancreatic adenocarcinoma undergoing PD.

METHODS

Patients >65 years of age who underwent PD for pancreatic adenocarcinoma were identified from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database (2008-2015). Analyses were stratified by hospital volume and then surgeon volume, creating four volume cohorts: low-low (low hospital, low surgeon), low-high (low hospital, high surgeon), high-low (high hospital, low surgeon), high-high (high hospital, high surgeon). Propensity scores were created for the odds of undergoing surgery with high-volume surgeons. Following matching, multivariable analysis was used to assess the impact of surgeon volume on outcomes within each hospital volume cohort.

RESULTS

In total, 2450 patients were identified: 54.3% were treated at high-volume hospitals (27.0% low-volume surgeons, 73.0% high-volume surgeons) and 45.7% were treated at low-volume hospitals (76.9% low-volume surgeons, 23.1% high-volume surgeons). On matched multivariable analysis, there were no significant differences in the risk of major complications, 90-day mortality, and 30-day readmission based on surgeon volume within the low and high hospital volume cohorts.

CONCLUSION

Compared with surgeon volume, hospital volume is a more significant factor in predicting short-term outcomes after PD. This suggests that a focus on resources and care pathways, in combination with volume metrics, is more likely to achieve high-quality care for patients undergoing PD across all hospitals.

Effect of surgeon-related factors on outcome of retinal detachment surgery: analyses of data in Japan-retinal detachment registry

The purpose of this study was to investigate the effects of surgeon-related factors on the surgical outcome of pars plana vitrectomy (PPV) and scleral buckling (SB) surgery on eyes with a rhegmatogenous retinal detachment (RRD). This was a nationwide, multicenter, observational study of the data in the Japan-RD Registry. Registered cases that had undergone surgery for a RRD by 128 accredited surgeons in 26 institutions were studied. The surgeon-related factors that significantly affected surgical success and visual outcomes of simple RRD treated by PPV or SB at 6 months postoperatively were analyzed and compared. Among 3446 registered cases, 2533 cases met the inclusion criteria with 1896 in the PPV group and 637 cases in the SB group. The median total number of lifetime cases was 150 and the rate of surgeries/year was 22. Multivariate regression analyses showed that the number and rate of surgeries/year were not significantly associated with the surgical outcome in the PPV group. However, surgeons with a higher average annual number of surgeries had significantly better surgical outcomes in the SB group (P = 0.038). Analyses of a nationwide registry showed that SB but not PPV surgeries require sufficient experience and case numbers to acquire and maintain skills to treat RRDs successfully.

Social determinants of health associated with poor outcome for rural patients following resected pancreatic cancer

BACKGROUND

The impact of rurality on outcome for patients who had resected pancreatic ductal adenocarcinoma (PDAC) is unclear. We hypothesize that poor outcomes for rural patients are associated with adverse social determinants of health (SDoH). The objective of this study is to assess the difference in overall survival (OS) of PDAC patients between rural, urban, and contributing factors.

METHODS

A cohort of 25,536 patients diagnosed with stage I-III pancreatic adenocarcinoma from 2003 to 2011 and underwent resection were evaluated from the National Cancer Database. Socioeconomic/demographic, clinicopathological, and treatment variables were compared between rural and urban residences. The 5-year OS was calculated using the Kaplan-Meier method. The Cox regression model was used to assess factors associated with OS. P value <0.05 was considered significant.

RESULTS

In univariate analysis, the rural residence was a predictor of poor OS. The 5-year OS for rural (N=4,389) and urban (N=21,147) was 18.8% (95% CI: 17.4-20.2%) and 22.3% (95% CI: 21.6-22.9%; P<0.0001), respectively. The risk of all causes of death was 10.3% higher (P<0.0001) in rural than urban patients. In multivariable analysis, rurality was not an independent predictor of OS (P=0.407). Independent predictors of worse OS included adverse social determinants of health associated with the rural population and these included a low income (P<0.0001), low education level (P<0.01), low insurance status (P<0.01), and treatment at a low-volume facility (P<0.0001).

CONCLUSIONS

Rural/urban outcome disparities for resected stage I-III pancreatic cancer outcome can be explained by adverse social determinants of health associated with rural population.

Implementation of a regional reference center in pancreatic surgery. Experience after 631 procedures

INTRODUCTION

The main objective of this study is to determine whether our unit meets the quality standards required by the scientific community from the reference centers for pancreatic surgery in terms of peri-operative results. The secondary objectives are to compare the different pancreatic surgery techniques performed in terms of early post-operative morbidity and mortality and to analyze the impact of the resections added in these terms.

METHOD

Descriptive, retrospective and single-center study, corresponding to the period 2006-2019. The results obtained were compared with the proposed quality standards, by Bassi et al. and Sabater et al., required from the reference centers in pancreatic surgery. The sample was divided according to surgical technique and compared in terms of early post-operative morbidity and mortality, studying the impact of extended vascular and visceral resections. All patients undergoing pancreatic surgery in our unit due to pancreatic, malignant and benign pathology were included, since it was implemented as a reference center. Emergency procedures were excluded.

RESULTS

631 patients were analyzed. The values ​​obtained in the quality standards are in range. The most frequent surgery was pancreaticoduodenectomy, which associated higher peri-operative morbidity and mortality rates (P ≤ .05). The extended vascular resections impacted the pancreaticoduodenectomy group, associating a longer mean stay (P = .01) and a higher rate of re-interventions (P = .02).

CONCLUSIONS

The experience accumulated allows to meet the required quality standards, as well as perform extended resections to pancreatectomy with good results in terms of post-operative morbidity and mortality.

Undertreatment of Pancreatic Cancer: The Intersection of Bias, Biology, and Geography

Pancreatic cancer is the third leading cause of cancer deaths in the United States. Black patients with pancreatic cancer experience higher incidence and increased mortality. Although racial biologic differences exist, socioeconomic status, insurance type, physician bias, and patient beliefs contribute to the disparities in outcomes observed among patients who are Black, indigenous, and people of color.

Associations of gender, race, and ethnicity with disparities in short-term adverse outcomes after pancreatic resection for cancer

BACKGROUND

Several studies have identified disparities in pancreatic cancer treatment associated with gender, race, and ethnicity. There are limited data examining disparities in short-term adverse outcomes after pancreatic resection for cancer. The aim of this study is to evaluate associations of gender, race, and ethnicity with morbidity and mortality after pancreatic resection for malignancy.

METHODS

The American College of Surgeons National Surgical Quality Improvement database was retrospectively reviewed. The χ² test and Student's t-test were used for univariable analysis and hierarchical logistic regression for multivariable analysis.

RESULTS

Morbidity and major morbidity after pancreaticoduodenectomy are associated with male gender, Asian race, and Hispanic ethnicity, whereas 30-day mortality is associated with the male gender. Morbidity and major morbidity after distal pancreatectomy are associated with the male gender. Morbidity after pancreaticoduodenectomy is independently associated with male gender, Asian race, and Hispanic ethnicity; major morbidity is independently associated with male gender and Asian race, and mortality is independently associated with Hispanic ethnicity.

CONCLUSIONS

Gender, race, and ethnicity are independently associated with morbidity after pancreaticoduodenectomy for cancer; gender and race are independently associated with major morbidity; and ethnicity is independently associated with mortality. Further studies are warranted to determine the basis of these associations.

Proclivity to Explore Locally Advanced Pancreas Cancer Is Not Associated with Surgeon Volume

BACKGROUND AND PURPOSE

There is limited high-level evidence to guide locally advanced pancreas cancer (LAPC) management. Recent work shows that surgeons' preferences in LAPC management vary broadly. We sought to examine whether surgeon volume was associated with attitudes regarding LAPC management.

METHODS

An electronic survey was distributed by email to an international cohort of pancreas surgeons to evaluate practice patterns regarding LAPC management. Clinical vignette-based questions evaluated surgeons' attitudes regarding patient eligibility and the proclivity to offer exploration. Surgeons were classified into "low-" or "high-volume" categories according to thresholds of self-reported annual pancreatectomy volume. Surgeon's attitudes regarding LAPC management and inclination to consider exploration were compared across annual volume categories.

RESULTS

A total of 153 eligible responses were received from 4 continents, for an estimated response rate of 10.6%. Median duration of practice was 12 years (IQR 6-20). Most respondents reported >25 cases/year (89, 58.2%), of which 34 (22.2%) reported >50. Compared to surgeons with <25 cases/year, surgeons with >25 cases/year practiced longer (median 15 vs. 7.5 years, P<0.001) and were more likely to "always" recommend neoadjuvant chemotherapy (83.2% vs. 56.3%, P=0.001). Surgeons performing >50 cases/year were more likely to offer arterial resection (70.6% vs. 43.7%, P=0.006). The willingness to offer (or defer) exploration did not differ across any categories of surgeons' annual case volume.

CONCLUSIONS

In an international survey of pancreas surgeons, the proclivity to consider exploration for LAPC was not associated with multiple categories of surgeon volume. Better evidence is needed to define the optimal management approach to LAPC.

Health Care Disparities and the Future of Pancreatic Cancer Care

There have been tremendous advances in the diagnosis and treatment of pancreatic cancer in the past decade, yet we are failing to achieve equitable outcomes for all patient populations. Disparities exist in the incidence, diagnosis, treatment, and outcomes of patients with pancreatic cancer. Inequities are based on racial and ethnic group, sex, socioeconomic status, and geography. To address disparities, future steps must focus on research methods, including collection and methodology, and policy measures, including access, patient tools, hospital incentives, and workforce diversity. Through these comprehensive efforts, we can begin to rectify inequitable care for treatment of patients with pancreatic cancer.

Does the Volume-Outcome Association in Pancreas Cancer Surgery Justify Regionalization of Care? A Review of Current Controversies

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.

Association between Stroke Quality Assessments and Mortality within 30 Days among Patients Who Underwent Hemorrhagic Stroke Surgeries in South Korea

INTRODUCTION

In South Korea, to improve the quality of medical services provided to stroke patients, stroke quality assessments have been implemented since 2006. To further promote improvement of care, financial incentives were introduced since 2012. This study aims to examine the association between stroke quality assessments and mortality within 30 days among South Korean adults who underwent hemorrhagic stroke surgeries to provide evidence of the importance of such assessments.

METHODS

Data from 45,741 patients from 374 healthcare organizations, derived from the 2013-2016 claims data of the Korean Health Insurance Review and Assessment Service, were examined. To ensure homogeneity, only patients who underwent hemorrhagic stroke surgeries were selected. Healthcare organizations were classified based on whether stroke quality assessments were conducted. The dependent variable of this study was death within 30 days of hospitalization. A generalized linear mixed model was constructed to analyze the association between variables.

RESULTS

Healthcare organizations without stroke quality assessments exhibited a higher risk of mortality than those that did (adjusted odds ratio [OR] = 1.53, 95% confidence interval [CI] = 1.16-2.01). Among healthcare organizations with the lowest volume, those without stroke quality assessments had a higher risk of mortality than those that did (tertile 1 [low], adjusted OR = 1.38, 95% CI = 1.04-1.84). Among rural healthcare organizations, those without assessments had a higher risk of mortality than did those that did (adjusted OR = 1.61, 95% CI = 1.06-2.43).

CONCLUSIONS

The study identified a significant relationship between stroke quality assessments and 30-day mortality. Healthcare organizations without stroke quality assessments may exhibit a comparatively higher risk of mortality. Future interventions to minimize mortality and provide evidence for policymakers and healthcare leaders could involve expanding the scope of stroke quality assessment.

Re-defining a high volume center for pancreaticoduodenectomy

BACKGROUND

The purpose of this study was to re-evaluate the previously utilized definitions of high volume center for pancreaticoduodenectomy to determine/establish an objective, evidence based threshold of hospital volume associated with improvement in perioperative mortality.

METHODS

Patients who underwent pancreaticoduodenectomy were identified using the National Cancer Database from 2004 to 2015. The relationship between hospital volume and 90-day mortality was assessed using a logistic regression model. Receiver Operator Characteristic analysis was performed and Youden's statistic was utilized to calculate the optimal cut offs.

RESULTS

42,402 patients underwent elective Pancreaticoduodenectomy at 1238 unique hospitals. A logistic regression was performed which showed a significant inverse linear association between institutional volume and overall 90 day mortality. The maximum improvement in 90 day mortality is seen if the average annual hospital volume was greater than 9 (OR = 0.647 (0.595-0.702), p < 0.0001). When analysis is limited to hospitals that performed >9 cases per year, the maximum improvement in 90 day mortality was noticed at 36 cases per year (OR = 0.458 (0.399-0.525), p < 0.0001).

CONCLUSIONS

Based on our results, we recommend defining low, medium, and high volume centers for pancreaticoduodenectomy as hospitals with average annual volume less than 9, 9 to 35, and more than 35 cases per year, respectively.

Decision points in pancreatoduodenectomy: Insights from the contemporary experts on prevention, mitigation, and management of postoperative pancreatic fistula

BACKGROUND

Despite abundant, high-level scientific evidence, there is no consensus regarding the prevention, mitigation, and management of clinically relevant pancreatic fistula after pancreatoduodenectomy. The aim of the present investigation is three-fold: (1) to analyze the multiple decision-making points for pancreatico-enteric anastomotic creation and fistula mitigation and management after pancreatoduodenectomy, (2) to reveal the practice of contemporary experts, and (3) to indicate avenues for future research to reduce the burden of clinically relevant pancreatic fistula.

METHODS

A 109-item questionnaire was sent to a panel of international pancreatic surgery experts, recognized for their clinical and scientific authority. Their practice habits and thought processes regarding clinically relevant pancreatic fistula risk assessment, anastomotic construction, application of technical adjuncts, and mitigation strategies, as well as postoperative management, was explored. Sixteen clinical vignettes were presented to reveal their certain approaches to unique situations-both common and uncommon.

RESULTS

Sixty experts, with a cumulative 48,860 pancreatoduodenectomies, completed the questionnaire. Their median pancreatectomy/pancreatoduodenectomy case volume was 1,200 and 705 procedures, respectively, with a median career duration of 22 years and 200 indexed publications. Although pancreatico-jejunostomy reconstruction with transperitoneal drainage is the standard operative approach for most authorities, uncertainty emerges regarding the employment of objective risk stratification and adaptation of practice to risk. Concrete suggestions are offered to inform decision-making in intimidating circumstances. Early drain removal is frequently embraced, while a step-up approach is unanimously invoked to treat severe clinically relevant pancreatic fistula.

CONCLUSION

A comprehensive conceptual framework of 4 sequential phases of decision-making is proposed-risk assessment, anastomotic technique, mitigation strategy employment, and postoperative management. Basic science studies and outcome analyses are proposed for improvement.

Implementation of a regional reference center in pancreatic surgery. Experience after 631 procedures

INTRODUCTION

The main objective of this study is to determine if our unit meets the quality standards required by the scientific community from the reference centers for pancreatic surgery in terms of peri-operative results. The secondary objectives are to compare the different pancreatic surgery techniques performed in terms of early post-operative morbidity and mortality and to analyze the impact of the resections added in these terms.

METHOD

Descriptive, retrospective and single-center study, corresponding to the period 2006-2019. The results obtained were compared with the proposed quality standards, by Bassi et al. and Sabater et al., required from the reference centers in pancreatic surgery. The sample was divided according to surgical technique and compared in terms of early post-operative morbidity and mortality, studying the impact of extended vascular and visceral resections. All patients undergoing pancreatic surgery in our unit due to pancreatic, malignant and benign pathology were included, since it was implemented as a reference center. Emergency procedures were excluded.

RESULTS

631 patients were analyzed. The values ??obtained in the quality standards are in range. The most frequent surgery was cephalic duodenopancreatectomy, which associated higher peri-operative morbidity and mortality rates (p ≤ 0.05). The extended vascular resections impacted the cephalic duodenopancreatectomy group, associating a longer mean stay (p = 0.01) and a higher rate of re-interventions (p = 0.02).

CONCLUSIONS

The experience accumulated allows to meet the required quality standards, as well as perform extended resections to pancreatectomy with good results in terms of post-operative morbi-mortality.

Assessing the influence of experience in pancreatic surgery: a risk-adjusted analysis using the American College of Surgeons NSQIP database

BACKGROUND

The association between higher surgical volume and better perioperative outcomes after pancreatectomy has been extensively demonstrated. However, how different notions of experience impact outcomes of surgeons operating within high-quality scenarios remains unclear.

METHODS

Self-reported experience parameters from ACS-NSQIP HPB-Collaborative surgeons were merged with 2014-2016 ACS-NSQIP clinical data. The association of various experience parameters with outcomes was investigated through uni- and multivariable analyses. Hierarchical regression assessed surgeon performance.

RESULTS

111/151 HPB-Collaborative surgeons provided responses (73.5%). Compared to the other 532 ACS-NSQIP surgeons performing pancreatectomy, HPB-Collaborative surgeons performed 7692/16,239 of the overall pancreatectomies (47.3%), with improved outcomes of serious morbidity, pancreatic fistula, reoperation, duration of stay and readmissions. Median age of respondents was 49 years and 92.8% were fellowship-trained. Median career and annual pancreatectomy volume were 400 and 35, respectively; median annual institutional volume was 100 resections. On unadjusted analyses, several aspects of experience were associated with the outcomes studied, especially for pancreatoduodenectomy; however, none remained significant after multivariable adjustment. Surgeons' profiling showed substantial homogeneity in performance for both pancreatoduodenectomy and distal pancreatectomy.

CONCLUSIONS

Contemporary data shows that for surgeons operating in high quality settings clinical outcomes are largely independent of indicators of greater experience.

Disparities in Pancreatic Cancer Treatment and Outcomes

Purpose: Pancreatic cancer remains a major health concern; in the next 2 years, it will become the second leading cause of cancer deaths in the United States. Health disparities in the treatment of pancreatic cancer exist across many disciplines, including race and ethnicity, socioeconomic status (SES), and insurance. This narrative review discusses what is known about these disparities, with the goal of highlighting targets for equity promoting interventions.

Methods: We performed a narrative review of health disparities in pancreatic cancer spanning greater than ten areas, including epidemiology, treatment, and outcome, using the PubMed NIH database from 2000 to 2019 in the Unites States.

Results: African Americans (AAs) tend to present at diagnosis with later stage disease. AAs and Hispanics have lower rates of surgical resection, are more likely to be treated at low volume hospitals, and often experience higher rates of morbidity and mortality compared to white patients, although control for confounders is often limited. Insurance and SES also factor into the delivery of treatment for pancreatic cancer.

Conclusion: Disparities by race and SES exist in the diagnosis and treatment of pancreatic cancer that are largely driven by race and SES. Improved understanding of underlying causes could inform interventions.

The impact of surgical experience and frequency of practice on perioperative outcomes in pancreatic surgery

OBJECTIVE

We aimed to determine the impact of surgical experience and frequency of practice on perioperative morbidity and mortality in pancreatic surgery.

METHODS

1281 patients that underwent pancreatic resections from 1993 to 2013 were retrospectively analyzed using logistic regression models. All cases were stratified according to the surgeon's level of experience, which was based on the number of previously performed pancreatic resections and the extent of received supervision (novice: n <  20 / intensive; intermediate: n = 21-90 / decreasing; and experienced surgeon: n > 90 / none). Additional stratification was based on the frequency of practice (sporadic: 3 resections > 6 weeks, frequent: 3 resections ≤6 weeks).

RESULTS

The novice and experienced categories were related to a decreased risk of postoperative pancreatic fistulas (odds ratio [OR] 0.46, 95% confidence interval [CI] 0.26-0.82 and 0.54, 95% CI 0.36-0.82) and in-hospital mortality (OR 0.45, 95% CI 0.17-1.16 and 0.42, 95% CI 0.21-0.83) compared to the intermediate category. Frequent practice was associated with a significantly lower risk of delayed gastric emptying (OR 0.56, 95% CI 0.38-0.83), postpancreatectomy hemorrhage (OR 0.64, 95% CI 0.42-0.98) and in-hospital mortality (OR 0.45, 95% CI 0.24-0.87).

CONCLUSIONS

Our results emphasize the importance of supervision within a pancreatic surgery training program. In addition, our data underline the need of a sufficient patient caseload to ensure frequent practice.

The Surgeon Volume-outcome Relationship: Not Yet Ready for Policy

OBJECTIVE

Increasing surgeon volume may improve outcomes for index operations. We hypothesized that there may be surrogate operative experiences that yield similar outcomes for surgeons with a low-volume experience with a specific index operation, such as esophagectomy.

BACKGROUND

The relationship between surgeon volume and outcomes has potential implications for credentialing of surgeons. Restrictions of privileges based on surgeon volume are only reasonable if there is no substitute for direct experience with the index operation. This study was aimed at determining whether there are valid surrogates for direct experience with a sample index operation-open esophagectomy.

METHODS

The Nationwide Inpatient Sample (2003-2009) was utilized. Surgeons were stratified into low and high-volume groups based on annual volume of esophagectomy. Surrogate volume was defined as the aggregate annual volume per surgeon of upper gastrointestinal operations including excision of esophageal diverticulum, gastrectomy, gastroduodenectomy, and repair of diaphragmatic hernia.

RESULTS

In all, 26,795 esophagectomies were performed nationwide (2003-2009), with a crude inhospital mortality rate of 5.2%. Inhospital mortality decreased with increasing volume of esophagectomies performed annually: 7.7% and 3.8% for low and high-volume surgeons, respectively (P < 0.0001). Among surgeons with a low-volume esophagectomy experience, increasing volume of surrogate operations improved the outcomes observed for esophagectomy: 9.7%, 7.1%, and 4.3% for low, medium, and high-surrogate-volume surgeons, respectively (P = 0.016).

CONCLUSIONS

Both operation-specific volume and surrogate volume are significant predictors of inhospital mortality for esophagectomy. Based on these observations, it would be premature to limit hospital privileges based solely on operation-specific surgeon volume criteria.

Short-term outcomes of pancreaticoduodenectomy in the state of Victoria: hospital resources are more important than volume

BACKGROUND

Pancreaticoduodenectomy (PD) is a high-risk procedure. Australian hospitals perform a relatively low volume of PD. This study sought to gain an understanding of hospital volume and short-term outcomes of the procedure in the Australian state of Victoria.

METHODS

The Dr Foster Quality Investigator tool was used to interrogate the Victorian Admitted Episodes Database for the Australian Classification of Health Intervention code for PD (30584) from July 2010 to June 2016. The data set included patients from a peer group of 14 hospitals that included all the public hospitals performing PD during this period. Patient characteristics, inpatient mortality, 30-day readmission rates and median length of stay were reported for each de-identified hospital.

RESULTS

There were 547 PD conducted over 6 years in 10 public hospitals. The median patient age was 65 years. Inpatient mortality was 2.7%. There was a significant risk adjusted difference in mortality between principal referral and other public hospitals. Annual hospital volume ranged from 3 to 20 PD, and there was no significant relationship between mortality, readmission rates or length of stay and hospital volume.

CONCLUSION

The inpatient mortality associated with PD in Victorian public hospitals is comparable to that seen in overseas studies. While hospital volume is relatively low, there does not seem to be a relationship between volume and short-term outcomes. Variability between hospital peer groups suggests that resource availability is more important than volume. The development of a procedure specific registry would be useful to test the outcomes of this study and determine long-term PD outcomes.

Restrictive Versus Liberal Fluid Regimens in Patients Undergoing Pancreaticoduodenectomy: a Systematic Review and Meta-Analysis

BACKGROUND

Pancreaticoduodenectomy is associated with significant morbidity and mortality which may be influenced by perioperative fluid management. It remains unclear whether liberal and restrictive fluid regimens impact mortality and morbidity in patients undergoing pancreaticoduodenectomy.

METHODS

Medline, EMBASE, Cochrane Library and clinicaltrials.gov were searched for studies comparing restrictive and liberal perioperative fluids in patients undergoing pancreaticoduodenectomy. Both prospective and retrospective studies in those undergoing pancreaticoduodenectomy were eligible for inclusion where the patient outcomes were stratified to restrictive and liberal perioperative fluid management regimens, with mortality as the primary outcome. Following study identification, a systematic review and meta-analysis with trial sequential analysis was completed.

RESULTS

Thirteen studies including five prospective trials and eight retrospective analyses totalling 3062 patients were included. Restrictive fluid regimens were associated with a significant reduction in mortality compared to liberal fluid regimens for the overall cohort (odds ratio 0.54; 95% CI 0.31-0.94, p = 0.03). There were no significant differences in complication profile. Subgroup analysis revealed this result was contributed to significantly by retrospective studies. The results of the trial sequential analysis suggest this mortality benefit may be due to a type I statistical error and that further patient numbers are required for definitive conclusions.

CONCLUSIONS

Restrictive fluid regimens are associated with a reduction in mortality following pancreaticoduodenectomy. The clinical relevance of this finding needs to be interpreted pragmatically given the lack of association with significant causes of morbidity and in considering the results of the recently published RELIEF study.

Do Not Blame the Resident: the Impact of Surgeon and Surgical Trainee Experience on the Occurrence of Intraoperative Adverse Events (iAEs) in Abdominal Surgery

OBJECTIVE

Intraoperative adverse events (iAEs) are defined as inadvertent injuries that occur during an operation and are associated with increased mortality, morbidity, and health care costs. We sought to study the impact of attending surgeon experience as well as resident training level on the occurrence of iAEs.

DESIGN

The institutional American College of Surgeons-National Surgical Quality Improvement Program and administrative databases for abdominal surgeries were linked and screened for iAEs using the International Classification of Diseases, Ninth Revision, Clinical Modification-based Patient Safety Indicator "accidental puncture/laceration." Each flagged record was systematically reviewed to confirm iAE occurrence and determine the number of years of independent practice of the attending surgeon and the postgraduate year (PGY) of the assisting resident at the time of the operation. The attending surgeon experience was divided into quartiles (<6 years, 6-13 years, 13-20 years, >20 years). The resident experience level was defined as Junior (PGY-1 to PGY-3) or Senior (PGY-4 or PGY-5). Univariate/bivariate then multivariable logistic regression analyses adjusting for patient demographics, comorbidities, and operation type and/or complexity (using RVUs as a proxy) were performed to assess the independent impact of resident and attending surgeon experience on the occurrence of iAEs.

SETTING

A large tertiary care teaching hospital.

PARTICIPANTS

Patients included in the 2007-2012 ACS-NSQIP that had an abdominal surgery performed by both an attending surgeon and a resident.

RESULTS

A total of 7685 operations were included and iAEs were detected in 159 of them (2.1%). Junior residents participated in 1680 cases (21.9%), while senior residents were involved in 6005 (78.1%). The iAE rates for attending surgeons with <6, 6-13, 13-20, and >20 years of experience were 2.7%, 1.7%, 2.4%, and 1.4%, respectively. In multivariable analyses, the risk of occurrence of an iAE was significantly decreased for surgeons with >20 years of experience compared to those with <6 years of experience (odds ratio=0.52, 95% confidence interval 0.32-0.86, p = 0.011). On bivariate analyses, iAEs occurred in 1.2% of junior resident cases, while senior residents had an iAE rate of 2.3%. However, after risk adjustment on multivariable analyses, the resident experience level did not significantly impact the rate of iAEs.

CONCLUSIONS

The surgeon's level of experience, but not the resident's, is associated with the occurrence of iAEs in abdominal surgery. Efforts to improve patient safety in surgery should explore the value of pairing junior surgeons with the more experienced ones thru formalized coaching programs, rather than focus on curbing resident operative autonomy.

Geographical Accessibility of the Referral Networks in France. Intermediate Results from the IGéAS Research Program

Rare cancer patients face lower survival and experience delays in diagnosis and therapeutic mismanagement. Considering the specificities of rare cancers, referral networks have been implemented in France to improve the management and survival of patients. The IGéAS research program aims to assess the networks’ ability to reduce inequalities. Data analysis of the IGéAS cohort (n = 20,590, sarcoma diagnosed between 2011 and 2014) by gathering medical data and geographical index will identify risk factors associated with the belated access to expertise or with no access to expertise. Intermediate results show that referral networks give sarcoma patients access to sarcoma expertise despite the remoteness of some of them. Regional expert centers mostly receive requests from within their area while national referral centers receive requests from the whole country. Delays in the access to expertise may be reduced by making outside practitioners more sensitive to the issues of rare cancers. The perception and involvement of outside practitioners in this device will be assessed using a qualitative survey. All the results are discussed and will contribute to design guidelines to improve early access to expertise and reduce inequalities. Results of the IGéAS research program may contribute to the assessment of referral sarcoma networks and provide some useful lessons to improve cancer care management.

Impact of neurosurgeon specialization on patient outcomes for intracranial and spinal surgery: a retrospective analysis of the Nationwide Inpatient Sample 1998–2009

OBJECTIVE

The subspecialization of neurosurgical practice is an ongoing trend in modern neurosurgery. However, it remains unclear whether the degree of surgeon specialization is associated with improved patient outcomes. The authors hypothesized that a trend toward increased neurosurgeon specialization was associated with improved patient morbidity and mortality rates.

METHODS

The Nationwide Inpatient Sample (NIS) was used (1998–2009). Patients were included in a spinal analysis cohort for instrumented spine surgery involving the cervical spine (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 81.31–81.33, 81.01–81.03, 84.61–84.62, and 84.66) or lumbar spine (codes 81.04–81.08, 81.34–81.38, 84.64–84.65, and 84.68). A cranial analysis cohort consisted of patients receiving a parenchymal excision or lobectomy operation (codes 01.53 and 01.59). Surgeon specialization was measured using unique surgeon identifiers in the NIS and defined as the proportion of a surgeon’s total practice dedicated to cranial or spinal cases.

RESULTS

A total of 46,029 and 231,875 patients were identified in the cranial and spinal analysis cohorts, respectively. On multivariate analysis in the cranial analysis cohort (after controlling for overall surgeon volume, patient demographic data/comorbidities, hospital characteristics, and admitting source), each percentage-point increase in a surgeon’s cranial specialization (that is, the proportion of cranial cases) was associated with a 0.0060 reduction in the log odds of patient mortality (95% CI 0.0034–0.0086) and a 0.0042 reduction in the log odds of morbidity (95% CI 0.0032–0.0052). This resulted in a 15% difference in the predicted probability of mortality for neurosurgeons at the 75th versus the 25th percentile of cranial specialization. In the spinal analysis cohort, each percentage-point increase in a surgeon’s spinal specialization was associated with a 0.0122 reduction in the log odds of mortality (95% CI 0.0074–0.0170) and a 0.0058 reduction in the log odds of morbidity (95% CI 0.0049–0.0067). This resulted in a 26.8% difference in the predicted probability of mortality for neurosurgeons at the 75th versus the 25th percentile of spinal specialization.

CONCLUSIONS

For both spinal and cranial surgery patient cohorts derived from the NIS database, increased surgeon specialization was significantly and independently associated with improved mortality and morbidity rates, even after controlling for overall case volume.

Outcome of Pancreaticoduodenectomy at Low-Volume Centre in Tier-II City of India

Currently, pancreaticoduodenectomy (PD) is considered a common and feasibly performed surgery for periampullary tumours, but it is still a high-risk surgical procedure with potential morbidity and mortality rates. Previously, it was emphasised for the need of high-volume centres to perform specialised surgery such as PD. The authors have made an attempt to know the relation between low-volume centre and outcomes of PD. The study was conducted in a Tier-II city referral hospital located in Karnataka, India. A total of 37 patients with suspected periampullary neoplasms underwent surgical exploration with curative intent over a period of 4 years, i.e. from May 2012 to May 2016. Out of 37 patients, 26 underwent PD, either classic Whipple resection (n = 01) or pylorus-preserving modification (n = 25). In 11 patients, resection was not possible, where biliary and gastric drainage procedures were done. All patients were treated by standardised post-operative care protocols for pancreatic resection used at our centre. We recorded the perioperative outcome along with demographics, indications for surgery, and pre- and intra-operative factors of PD. Post-operative pancreatic fistulae were evident in 4 patients. Two patients had hepaticojejunostomy leak. One patient had chyle leak. Three patients had infection at the surgical site. One patient had post-operative pneumonia leading to mortality. None of the patients had post-op haemorrhage. The surgeon volume and surgeon experience may have minimal contributing factor in post-operative morbidity, especially if there is availability of well-equipped ICU and imaging facilities, along with well-experienced personnel like oncosurgeon, anaesthesiologist, intensivist, radiologist, and nursing staff. There is a need of a multicentre study from Tier-II city hospitals/low-volume centres and high-volume centres to come with perioperative surgical outcomes following PD.

Factors leading to pancreatic resection in patients with pancreatic cancer: a national perspective

Background

Resection is the only option for potential cure in pancreatic cancer. Patients admitted for resection may have the procedure deferred during their hospitalization. We aim to identify factors that lead pancreatic cancer patients to undergo resection.

Methods

An analysis utilizing the Nationwide Inpatient Sample (NIS) database, 2003-2009. Study population included adults (≥18 years) with pancreatic cancer who underwent either pancreatic resection or other interventions. Surgeon volume classified based on the median into low and high-volume surgeon.

Results

Eleven thousand three hundred and sixty-five patients were included; 68.0% underwent pancreatic resection, while 32.0% had other interventions. The majority of patients resected were <60 years old, female, with higher annual household income (P<0.05 for all). Patients with Medicaid coverage and comorbidity scores ≥2 were least likely to undergo pancreatic resection. Resection was more likely for high-volume surgeons, high-volume hospitals and teaching hospitals (P<0.05 for all). Those managed by high-volume surgeons were at a lower risk of postoperative complications, lower mortality, shorter hospital stay, and lower healthcare costs (P<0.05 for all).

Conclusions

Patients' insurance type and economic status are significantly associated with their ability to achieve pancreatic resection. Surgeon experience and hospital volumes were also significantly associated with pancreatic resection, clinical and economic outcomes.

Polyester Preserves the Highest Breaking Point After Prolonged Incubation in Pancreatic Juice

BACKGROUND

The impact of suture materials on the development of pancreatic fistula after pancreaticoduodenectomy remains unclear. Thus, their choice among pancreatic surgeons is still mostly experience-based. Aim of the present study is to assess what is the best suture material to be used for pancreaticojejunostomy.

MATERIALS AND METHODS

The force needed to reach the breaking point of five widely used suture materials (polypropylene, polyester, polydioxanone, silk, and polyglactin 910) has been determined through a digital precision dynamometer at baseline and after 5 and 20 days of incubation in pancreatic juice, bile, or a mixture of both.

RESULTS

Regardless of the condition, polyglactin 910 has retained only 10% of its baseline force. Silk has maintained almost 90% of its initial force showing a very low baseline value of force. In pancreatic juice, polypropylene has lost less force compared to polyester (0.25 vs. 0.93 N; p = 0.03) and polydioxanone (0.25 vs. 3.67 N; p = 0.04). Polyester and polydioxanone have showed similar values of force. However, polydioxanone has lost a significant amount of force in pancreatic juice when compared to polyester (0.93 vs. 3.67 N; p = 0.03). Polyester has showed the highest value of force needed to reach the breaking point after 20 days of incubation in pancreatic juice.

CONCLUSIONS

After incubation in pancreaticobiliary secretions, polyglactin 910 loses almost all its force. Polypropylene preserves its characteristic, but polydioxanone and polyester show absolute higher breaking points, with polyester retaining the highest value of force needed to reach its breaking point after incubation in pancreatic juice.

Comparison of Surgeon Specialty in Open Ventral Hernia Repair

BACKGROUND

Ventral hernia repair is a common procedure and is undertaken by surgeons with varying training backgrounds. Outcomes after hernia repair depend on numerous factors, some being patient or surgeon specific. It remains unclear what the ideal roles are for general and plastic surgeons in open ventral hernia repair. We hypothesized that open ventral hernia repair by plastic surgeons is safe and comparable with general surgeons.

METHODS

We performed a retrospective observational study using data from the National Surgical Quality Improvement Program database from 2007 to 2013. Patients with a primary diagnosis of ventral hernia undergoing open repair were identified. Multivariate regression modeling was performed, adjusting for surgeon specialty, patient characteristics, common concurrent procedures, and the total number of concurrent procedures. Outcomes studied were major and minor 30-day complications, operation time, readmission, unplanned reoperation, and length of hospital stay.

RESULTS

We identified 53,746 patients who underwent open repair, 53,282 (99.1%) by general surgeons (GS) and 464 (0.9%) by plastic surgeons (PS). There were significantly different rates of concurrent panniculectomy (12.1% PS vs 2.4% GS) and component separation (24.8% PS vs 5.3% GS), representing increased PS case complexity. 52.3% of GS and 92.9% of PS performed panniculectomy without an alternate specialty surgeon. 81.3% of GS and 97.4% of PS performed component separation without an alternate specialty surgeon. The PS patients had a significantly longer uncorrected length of stay and operation time than GS patients (all P < 0.001). Similarly, PS was positively associated with uncorrected major and minor complications (P < 0.001). However, these relationships did not persist on multivariate analysis after adjusting for demographic characteristics, medical comorbidities, concurrent procedures, and total procedure load. Furthermore, PS was associated with lower odds of major complications (operating room, 0.49; P = 0.05) compared with GS.

CONCLUSIONS

Outcomes of hernia repair by plastic surgeons are comparable with general surgeons, despite plastic surgeons being involved in many complex cases. Interestingly, we identified that general surgeons are performing adjunctive procedures to ventral hernia previously handled by plastic surgeons. Although further study is warranted, we conclude that for open ventral hernia repair, plastic surgeons provide a comparable alternative to general surgeons.