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Kotecha K, Tree K, Ziaziaris WA, McKay SC, Wand H, Samra J, Mittal A. Centralization of Pancreaticoduodenectomy: A Systematic Review and Spline Regression Analysis to Recommend Minimum Volume for a Specialist Pancreas Service. Ann Surg 2024; 279:953-960. [PMID: 38258578 DOI: 10.1097/sla.0000000000006208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
OBJECTIVE Through a systematic review and spline curve analysis, to better define the minimum volume threshold for hospitals to perform (pancreaticoduodenectomy) and the high-volume center. BACKGROUND The pancreaticoduodenectomy (PD) is a resource-intensive procedure, with high morbidity and long hospital stays resulting in centralization towards high-volume hospitals; the published definition of high volume remains variable. MATERIALS AND METHODS Following a systematic review of studies comparing PD outcomes across volume groups, semiparametric regression modeling of morbidity (%), mortality (%), length of stay (days), lymph node harvest (number of nodes), and cost ($USD) as continuous variables were performed and fitted as a smoothed function of splines. If this showed a nonlinear association, then a "zero-crossing" technique was used, which produced "first and second derivatives" to identify volume thresholds. RESULTS Our analysis of 33 cohort studies (198,377 patients) showed 55 PDs/year and 43 PDs/year were the threshold value required to achieve the lowest morbidity and highest lymph node harvest, with model estimated df 5.154 ( P <0.001) and 8.254 ( P <0.001), respectively. The threshold value for mortality was ~45 PDs/year (model 9.219 ( P <0.001)), with the lowest mortality value (the optimum value) at ~70 PDs/year (ie, a high-volume center). No significant association was observed for cost ( edf =2, P =0.989) and length of stay ( edf =2.04, P =0.099). CONCLUSIONS There is a significant benefit from the centralization of PD, with 55 PDs/year and 43 PDs/year as the threshold value required to achieve the lowest morbidity and highest lymph node harvest, respectively. To achieve mortality benefit, the minimum procedure threshold is 45 PDs/year, with the lowest and optimum mortality value (ie, a high-volume center) at approximately 70 PDs/year.
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Affiliation(s)
- Krishna Kotecha
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Kevin Tree
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - William A Ziaziaris
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Siobhan C McKay
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Institute of Cancer and Genomic Science, University of Birmingham, Edgbaston, Birmingham United Kingdom
| | - Handan Wand
- Kirby Institute (formerly National Center in HIV Epidemiology and Clinical Research), University of New South Wales, Sydney, NSW
| | - Jaswinder Samra
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia
- Australian Pancreatic Center, Sydney, Australia
| | - Anubhav Mittal
- Department of Upper Gastrointestinal Surgery, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Northern Clinical School, The University of Sydney, Sydney, New South Wales, Australia
- Australian Pancreatic Center, Sydney, Australia
- University of Notre Dame, Sydney
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Hansen D, Itotoh F, Helena K, Aitken RJ. Observations from Australia's National Surgical Mortality Audit. World J Surg 2023; 47:3140-3148. [PMID: 37882828 DOI: 10.1007/s00268-023-07205-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND Australia is the only country with a national surgical mortality audit. Every Australian surgical mortality is independently and externally reviewed by another surgeon. Extensive educational feedback to surgeons and hospitals is provided through individual patient reviews, state and national symposia and reports, and the distribution of deidentified informative cases. This study reports a longitudinal analysis of the Australian surgical morality audit. METHODS The standardised mortality ratio (SMR) was calculated for each state and territory, nine surgical specialties and nationally. The index year used was 2016, or every 5 years for those states with earlier data. Overall data were analysed in three groups-all deaths, postoperative deaths and non-operative deaths. Overall specialty data were analysed nationally. RESULTS There was a consistent progressive fall, usually in excess of 20%, in the SMR in each state and territory and by specialty when compared to the index year. This was statistically significant nationally (p = 0.044). The same change was observed in earlier years in states with longer-term data. CONCLUSION The period of this observational study has been associated with a nationwide fall in surgical mortality. As other improvements in care will have occurred during this period, the contribution that Australia's national mortality audit made towards the lower surgical mortality cannot be stated with certainty.
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Affiliation(s)
- Dylan Hansen
- Royal Australasian College of Surgeons (RACS), Melbourne, Australia
| | - Franca Itotoh
- Royal Australasian College of Surgeons (RACS), Melbourne, Australia
| | - Kopunic Helena
- Royal Australasian College of Surgeons (RACS), Melbourne, Australia
| | - R James Aitken
- Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, WA, 6009, Australia.
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Silva T, Wagler A, Nelson D, O'Connor V. Quality of life after pancreatoduodenectomy: Is the outcome predetermined by the diagnosis? J Surg Oncol 2023; 128:1080-1086. [PMID: 37589271 DOI: 10.1002/jso.27417] [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: 05/04/2023] [Revised: 07/11/2023] [Accepted: 07/29/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND AND OBJECTIVES Non-physiological factors tied to the disease process may drive the diminished quality of life (QoL) after pancreatoduodenectomy (PD). We compared postoperative QoL among patients undergoing PD for either benign or malignant pathology. METHODS From 2012 to 2021, 228 patients underwent PD in a large healthcare system. Eighty-two patients (36.0%) were interviewed using the EORTC QLQ-C30 questionnaire. A minimum of 6 months after surgery was required for the survey. QoL outcomes were compared based on diagnosis (benign vs. malignant). RESULTS Patient mean age was 65 years (21-82), and forty-seven (57%) were men. Most patients underwent surgery for cancer, 76% (n = 62). Grade B postoperative pancreatic fistula incidence was higher in benign cases (30% vs. 6.5%, p = 0.024). Weight loss was more common in malignancy (79% vs. 50%, p = 0.016). Carcinoma patients felt less useful, hopeful, reported less control of their life and certainty of the future, and were less satisfied with their appearance. Carcinoma patients also reported diminished memory, fear of relapse, and greater financial burden. CONCLUSIONS Long-term QoL is inferior in PD patients with carcinoma and is driven by the psychological and socioeconomic implications of malignancy. Supportive resources for pancreas cancer patients should be evaluated and optimized.
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Affiliation(s)
- Trevor Silva
- Department of Surgery, Riverside University Health System, Moreno Valley, California, USA
| | - Amy Wagler
- Department of Mathematical Sciences, The University of Texas at El Paso, El Paso, Texas, USA
| | - Daniel Nelson
- Department of Surgery, William Beaumont Army Medical Center, El Paso, Texas, USA
| | - Victoria O'Connor
- Department of Surgery, Kaiser Permanente Los Angeles, Los Angeles, California, USA
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Huerta CT, Collier AL, Hernandez AE, Rodriguez C, Shah A, Kronenfeld JP, Franceschi DF, Sleeman D, Livingstone AS, Thorson CM. Nationwide Outcomes of Pancreaticoduodenectomy for Pancreatic Malignancies: Center Volume Matters. Am Surg 2023; 89:6020-6029. [PMID: 37310685 PMCID: PMC10883718 DOI: 10.1177/00031348231184198] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Complex surgeries such as pancreaticoduodenectomies (PD) have been shown to have better outcomes when performed at high-volume centers (HVCs) compared to low-volume centers (LVCs). Few studies have compared these factors on a national level. The purpose of this study was to analyze nationwide outcomes for patients undergoing PD across hospital centers with different surgical volumes. METHODS The Nationwide Readmissions Database (2010-2014) was queried for all patients who underwent open PD for pancreatic carcinoma. High-volume centers were defined as hospitals where 20 or more PDs were performed per year. Sociodemographic factors, readmission rates, and perioperative outcomes were compared before and after propensity score-matched analysis (PSMA) for 76 covariates including demographics, hospital factors, comorbidities, and additional diagnoses. Results were weighted for national estimates. RESULTS A total of 19,810 patients were identified with age 66 ± 11 years. There were 6,840 (35%) cases performed at LVCs, and 12,970 (65%) at HVCs. Patient comorbidities were greater in the LVC cohort, and more PDs were performed at teaching hospitals in the HVC cohort. These discrepancies were controlled for with PSMA. Length of stay (LOS), mortality, invasive procedures, and perioperative complications were greater in LVCs when compared to HVCs before and after PSMA. Additionally, readmission rates at one year (38% vs 34%, P < .001) and readmission complications were greater in the LVC cohort. CONCLUSIONS Pancreaticoduodenectomy is more commonly performed at HVCs, which is associated with less complications and improved outcomes compared to LVCs.
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Affiliation(s)
| | - Amber L Collier
- DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL, USA
| | | | - Cindy Rodriguez
- Florida State University College of Medicine, Tallahassee, FL, USA
| | - Ankit Shah
- University of Miami Miller School of Medicine, Miami, FL, USA
| | - Joshua P Kronenfeld
- DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL, USA
| | - Dido F Franceschi
- DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL, USA
- Division of Surgical Oncology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Danny Sleeman
- DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL, USA
- Division of General Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Alan S Livingstone
- DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL, USA
- Division of Surgical Oncology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Chad M Thorson
- DeWitt Daughtry Family Department of Surgery, University of Miami, Miami, FL, USA
- Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
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