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Cawich SO, Cabral R, Douglas J, Thomas DA, Mohammed FZ, Naraynsingh V, Pearce NW. Whipple's procedure for pancreatic cancer: training and the hospital environment are more important than volume alone. SURGERY IN PRACTICE AND SCIENCE 2023; 14:100211. [PMID: 39845848 PMCID: PMC11749909 DOI: 10.1016/j.sipas.2023.100211] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/14/2023] [Accepted: 08/15/2023] [Indexed: 01/24/2025] Open
Abstract
Background In our center, patients with pancreatic cancer traditionally had Whipple's resections by general surgery teams until January 2013 when a hepatopancreatobiliary (HPB) was introduced. We compared outcomes before and after introduction of HPB teams. Methods Data were collected from the records of all patients booked for Whipple's resections over a 12-year period. The data were divided into two groups: Group A consisted of the 6-year period from January 1, 2007 to December 30, 2012 during which all resections were performed by GS teams. Group B comprised patients in the 6-year period from January 1, 2013 to December 30, 2019 during which operations were performed by HPB teams. All statistical analyses were carried out using SPSS ver 16.0 and a P Value <0.05 was considered statistically significant. Results The patients selected for Whipple's resections in Group A had statistically better performance status and lower anaesthetic risk. Despite this, patients in Group A had higher conversions to palliative operations (66% vs 5.3%), longer mean operating time (517±25 vs 367±54 min; P<0.0001), higher blood loss (3687±661 vs 1394±656 ml; P<0.0001), greater transfusion requirements (4.3±1.3 vs 1.9±1.4 units; P<0.001), greater likelihood of prolonged ICU stay (100% vs 40%; P=0.19), higher overall morbidity (75% vs 22.2%; P=0.02), higher major morbidity (75% vs 13.9%; P=0.013), more procedure-related complications (75% vs 9.7%; P=0.003) and higher mortality rates (75% vs 5.6%; P<0.0001). The HPB teams were more likely to perform vein resection and reconstruction to achieve clear margins (26.4% vs 0; P=0.57). 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.
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Affiliation(s)
- Shamir O. Cawich
- Department of Clinical Surgical Sciences, University of the West Indies, St Augustine Campus, Trinidad & Tobago, West Indies
| | - Robyn Cabral
- Department of Clinical Surgical Sciences, University of the West Indies, St Augustine Campus, Trinidad & Tobago, West Indies
| | - Jacintha Douglas
- Department of Clinical Surgical Sciences, University of the West Indies, St Augustine Campus, Trinidad & Tobago, West Indies
| | - Dexter A. Thomas
- Department of Clinical Surgical Sciences, University of the West Indies, St Augustine Campus, Trinidad & Tobago, West Indies
| | - Fawwaz Z. Mohammed
- Department of Clinical Surgical Sciences, University of the West Indies, St Augustine Campus, Trinidad & Tobago, West Indies
| | - Vijay Naraynsingh
- Department of Clinical Surgical Sciences, University of the West Indies, St Augustine Campus, Trinidad & Tobago, West Indies
| | - Neil W. Pearce
- Department of Surgery, Southampton University NHS Trust, Southampton, United Kingdom SO16DP
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Kanwat S, Singh H, Sharma AK, Sharma V, Gupta P, Gupta V, Yadav TD, Gupta R. Pancreatic Dysfunction and Reduction in Quality of Life Is Common After Pancreaticoduodenectomy. Dig Dis Sci 2023:10.1007/s10620-023-07966-6. [PMID: 37160540 DOI: 10.1007/s10620-023-07966-6] [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: 01/17/2023] [Accepted: 05/02/2023] [Indexed: 05/11/2023]
Abstract
BACKGROUND Improvements in survival after pancreaticoduodenectomy has increased the number of patients potentially at risk of pancreatic insufficiency. AIMS We studied long-term (> 1 year) pancreatic functions (endocrine and exocrine) after pancreaticoduodenectomy and aimed to recognize the impact of various clinicopathological factors and postoperative complications on pancreatic functions. METHODS All patients who underwent pancreaticoduodenectomy at least 1 year prior were recruited from July 2020 to December 2021. Endocrine function was assessed using HbA1c, fasting blood sugar and postprandial blood sugar levels. Pancreatic exocrine function was assessed clinically with history of steatorrhea and objectively with quantitative estimation of fecal elastase-1 levels in stool samples. Volume of remnant pancreas, parenchymal thickness and duct diameter were assessed by computed tomography. Quality of life assessment was done using SF-36 questionnaire. RESULTS Of the 106 patients assessed, 64 patients met the inclusion criteria. Endocrine insufficiency was noted in 51.6%, and 34.3% had new onset diabetes mellitus. The incidence of pancreatic exocrine insufficiency was 87.5% and severe insufficiency was found in 62.5% of patients. Twenty-nine (45.3%) patients had both exocrine and endocrine insufficiency. Patients with CRPOPF had higher risk of severe exocrine insufficiency (5 vs. 2, OR 1.57(0.28-8.81) p = 0.6). The SF-36 scores were lower than general population especially in role limitation due to physical health, role limitation due to emotional problems, energy/fatigue, general health perception and health change domains. CONCLUSION Post-pancreaticoduodenectomy patients have a high frequency of pancreatic insufficiency and should be screened for same. The post-operative pancreatic fistula increases the risk of pancreatic exocrine insufficiency.
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Affiliation(s)
- Shradha Kanwat
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Harjeet Singh
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), F-block, Nehru Hospital, Sector 12, Chandigarh, India.
| | - Arun Kumar Sharma
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishal Sharma
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Gupta
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikas Gupta
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Thakur Deen Yadav
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajesh Gupta
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Cawich SO, Thomas DA, Pearce NW, Naraynsingh V. Whipple’s pancreaticoduodenectomy at a resource-poor, low-volume center in Trinidad and Tobago. World J Clin Oncol 2022; 13:738-747. [PMID: 36212600 PMCID: PMC9537505 DOI: 10.5306/wjco.v13.i9.738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/22/2022] [Accepted: 08/17/2022] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Shamir O Cawich
- Department of Surgery, Port of Spain General Hospital, Port of Spain 000000, Trinidad and Tobago
| | - Dexter A Thomas
- Department of Surgery, Port of Spain General Hospital, Port of Spain 000000, Trinidad and Tobago
| | - Neil W Pearce
- Department of Surgery, Southampton General Hospital National Health Services Trust, Southampton SO16 6YD, United Kingdom
| | - Vijay Naraynsingh
- Department of Surgery, Port of Spain General Hospital, Port of Spain 000000, Trinidad and Tobago
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Cawich SO, Pearce NW, Naraynsingh V, Shukla P, Deshpande RR. Whipple’s operation with a modified centralization concept: A model in low-volume Caribbean centers. World J Clin Cases 2022; 10:7620-7630. [PMID: 36158490 PMCID: PMC9372853 DOI: 10.12998/wjcc.v10.i22.7620] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 05/05/2022] [Accepted: 06/26/2022] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Shamir O Cawich
- Department of Clinical Surgical Sciences, University of the West Indies, St Augustine 000000, Trinidad and Tobago
| | - Neil W Pearce
- University Surgical Unit, Southampton General Hospital, Southampton SO16 6YD, United Kingdom
| | - Vijay Naraynsingh
- Department of Clinical Surgical Sciences, University of the West Indies, St Augustine 000000, Trinidad and Tobago
| | - Parul Shukla
- Department of Surgery, Weill Cornell Medical College, New York, NY 10065, United States
| | - Rahul R Deshpande
- Department of Surgery, Manchester Royal Infirmary, Manchester M13 9WL, United Kingdom
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Hunger R, Seliger B, Ogino S, Mantke R. Mortality factors in pancreatic surgery: A systematic review. How important is the hospital volume? Int J Surg 2022; 101:106640. [PMID: 35525416 PMCID: PMC9239346 DOI: 10.1016/j.ijsu.2022.106640] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 04/18/2022] [Accepted: 04/21/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND How the extent of confounding adjustment impact (hospital) volume-outcome relationships in published studies on pancreatic cancer surgery is unknown. METHODS A systematic literature search was conducted for studies that investigated the relationship between volume and outcome using a risk adjustment procedure by querying the following databases: PubMed, Cochrane Central Register of Controlled Trials, Livivo, Medline and the International Clinical Trials Registry Platform (last query: 2020/09/16). Importance of risk-adjusting covariates were assessed by effect size (odds ratio, OR) and statistical significance. The impact of covariate adjustment on hospital (or surgeon) volume effects was analyzed by regression and meta-regression models. RESULTS We identified 87 studies (75 based on administrative data) with nearly 1 million patients undergoing pancreatic surgery that included in total 71 covariates for risk adjustment. Of these, 33 (47%) had statistically significant effects on short-term mortality and 23 (32%) did not, while for 15 (21%) factors neither effect size nor statistical significance were reported. The most important covariates for short term mortality were patient-specific factors. Concerning the covariates, single comorbidities (OR: 4.6, 95% CI: 3.3 to 6.3) had the strongest impact on mortality followed by hospital volume (OR: 2.9, 95% CI: 2.5 to 3.3) and the procedure (OR: 2.2, 95% CI: 1.9 to 2.5). Among the single comorbidities, coagulopathy (OR: 4.5, 95% CI: 2.8 to 7.2) and dementia (OR: 4.2, 95% CI: 2.2 to 8.0) had the strongest influence on mortality. The regression analysis showed a significant decrease hospital volume effect with an increasing number of covariates considered (OR: 0.06, 95% CI: 0.10 to -0.03, P < 0.001), while such a relationship was not observed for surgeon volume (P = 0.35). CONCLUSIONS This analysis demonstrated a significant inverse relationship between the extent of risk adjustment and the volume effect, suggesting the presence of unmeasured confounding and overestimation of volume effects. However, the conclusions are limited in that only the number of included covariates was considered, but not the effect size of the non-included covariates.
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Affiliation(s)
- Richard Hunger
- Faculty of Medicine, University Hospital Brandenburg, Brandenburg Medical School Theodor Fontane, Brandenburg, Germany
| | - Barbara Seliger
- Martin Luther University Halle-Wittenberg, Institute of Medical Immunology, Halle, Germany; Fraunhofer Institute for Cell Therapy and Immunology, Leipzig, Germany
| | - Shuji Ogino
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA; Program in MPE Molecular Pathological Epidemiology, Department of Pathology, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA; Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Rene Mantke
- Faculty of Medicine, University Hospital Brandenburg, Brandenburg Medical School Theodor Fontane, Brandenburg, Germany; Faculty of Health Sciences, Brandenburg Medical School Theodor Fontane, Brandenburg, Germany.
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Panni RZ, Panni UY, Liu J, Williams GA, Fields RC, Sanford DE, Hawkins WG, Hammill CW. Re-defining a high volume center for pancreaticoduodenectomy. HPB (Oxford) 2021; 23:733-738. [PMID: 32994102 DOI: 10.1016/j.hpb.2020.09.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/15/2020] [Accepted: 09/08/2020] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Roheena Z Panni
- Department of Surgery, Washington University in Saint Louis, USA.
| | - Usman Y Panni
- Department of Surgery, Washington University in Saint Louis, USA; Division of Hepatobiliary & Pancreatic Surgery, Washington University in Saint Louis, USA
| | - Jingxia Liu
- Department of Surgery, Washington University in Saint Louis, USA; Division of Public Health Sciences, Washington University in Saint Louis, USA
| | - Gregory A Williams
- Department of Surgery, Washington University in Saint Louis, USA; Division of Hepatobiliary & Pancreatic Surgery, Washington University in Saint Louis, USA
| | - Ryan C Fields
- Department of Surgery, Washington University in Saint Louis, USA; Division of Surgical Oncology, Washington University in Saint Louis, USA
| | - Dominic E Sanford
- Department of Surgery, Washington University in Saint Louis, USA; Division of Hepatobiliary & Pancreatic Surgery, Washington University in Saint Louis, USA
| | - William G Hawkins
- Department of Surgery, Washington University in Saint Louis, USA; Division of Hepatobiliary & Pancreatic Surgery, Washington University in Saint Louis, USA
| | - Chet W Hammill
- Department of Surgery, Washington University in Saint Louis, USA; Division of Hepatobiliary & Pancreatic Surgery, Washington University in Saint Louis, USA
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Pancreatic Cancer Surgery Following Emergency Department Admission: Understanding Poor Outcomes and Disparities in Care. J Gastrointest Surg 2021; 25:1261-1270. [PMID: 32378096 PMCID: PMC7644583 DOI: 10.1007/s11605-020-04614-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 04/16/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND The impact of emergency department admission prior to pancreatic resection on perioperative outcomes is not well described. We compared patients who underwent pancreatic cancer surgery following admission through the emergency department (ED-surgery) with patients receiving elective pancreatic cancer surgery (elective) and outcomes. STUDY DESIGN The Nationwide Inpatient Sample database was used to identify patients undergoing pancreatectomy for cancer over 5 years (2008-2012). Demographics and hospital characteristics were assessed, along with perioperative outcomes and disposition status. RESULTS A total of 8158 patients were identified, of which 516 (6.3%) underwent surgery after admission through the ED. ED-surgery patients were more often socioeconomically disadvantaged (non-White 39% vs. 18%, Medicaid or uninsured 24% vs. 7%, from lowest income area 33% vs. 21%; all p < .0001), had higher comorbidity (Elixhauser score > 6: 44% vs. 26%, p < .0001), and often had pancreatectomy performed at sites with lower annual case volume (< 7 resections/year: 53% vs. 24%, p < .0001). ED-surgery patients were less likely to be discharged home after surgery (70% vs. 82%, p < .0001) and had higher mortality (7.4% vs. 3.5%, p < .0001). On multivariate analysis, ED-surgery was independently associated with a lower likelihood of being discharged home (aOR 0.55 (95%CI 0.43-0.70)). CONCLUSION Patients undergoing pancreatectomy following ED admission experience worse outcomes compared with those who undergo surgery after elective admission. The excess of socioeconomically disadvantaged patients in this group suggests factors other than clinical considerations alone drive this decision. This study demonstrates the need to consider presenting patient circumstances and preoperative oncologic coordination to reduce disparities and improve outcomes for pancreatic cancer surgery.
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Brunner M, Mücke F, Langheinrich M, Struller F, Rückert F, Welsch T, Distler M, Kersting S, Weber GF, Grützmann R, Krautz C. Proposal of a Standardized Questionnaire to Structure Clinical Peer Reviews of Mortality and Failure of Rescue in Pancreatic Surgery. J Clin Med 2021; 10:jcm10061281. [PMID: 33808921 PMCID: PMC8003630 DOI: 10.3390/jcm10061281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 03/16/2021] [Indexed: 01/28/2023] Open
Abstract
Background: Quality management tools such as clinical peer reviews facilitate root cause analysis and may, ultimately, help to reduce surgery-related morbidity and mortality. This study aimed to evaluate the reliability of a standardized questionnaire for clinical peer reviews in pancreatic surgery. Methods: All cases of in-hospital-mortality following pancreatic surgery at two high-volume centers (n = 86) were reviewed by two pancreatic surgeons. A standardized mortality review questionnaire was developed and applied to all cases. In a second step, 20 cases were randomly assigned to an online re-review that was completed by seven pancreatic surgeons. The overall consistency of the results between the peer review and online re-review was determined by Cohen’s kappa (κ). The inter-rater reliability of the online re-review was assessed by Fleiss’ kappa (κ). Results: The clinical peer review showed that 80% of the patient mortality was related to surgery. Post-operative pancreatic fistula (POPF) (36%) followed by post-pancreatectomy hemorrhage (PPH) (22%) were the most common surgical underlying (index) complications leading to in-hospital mortality. Most of the index complications yielded in abdominal sepsis (62%); 60% of the cases exhibited potential of improvement, especially through timely diagnosis and therapy (42%). There was a moderate to substantial strength of agreement between the peer review and the online re-review in regard to the category of death (surgical vs. non-surgical; κ = 0.886), type of surgical index complication (κ = 0.714) as well as surgical and non-surgical index complications (κ = 0.492 and κ = 0.793). Fleiss’ kappa showed a moderate to substantial inter-rater agreement of the online re-review in terms of category of death (κ = 0.724), category of common surgical index complications (κ = 0.455) and surgical index complication (κ = 0.424). Conclusion: The proposed questionnaire to structure clinical peer reviews is a reliable tool for root cause analyses of in-hospital mortality and may help to identify specific options to improve outcomes in pancreatic surgery. However, the reliability of the peer feedback decreases with an increasing specificity of the review questions.
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Affiliation(s)
- Maximilian Brunner
- Department of General and Visceral Surgery, University Hospital of Friedrich Alexander University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (F.M.); (M.L.); (F.S.); (S.K.); (G.F.W.); (R.G.); (C.K.)
- Correspondence:
| | - Franziska Mücke
- Department of General and Visceral Surgery, University Hospital of Friedrich Alexander University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (F.M.); (M.L.); (F.S.); (S.K.); (G.F.W.); (R.G.); (C.K.)
| | - Melanie Langheinrich
- Department of General and Visceral Surgery, University Hospital of Friedrich Alexander University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (F.M.); (M.L.); (F.S.); (S.K.); (G.F.W.); (R.G.); (C.K.)
| | - Florian Struller
- Department of General and Visceral Surgery, University Hospital of Friedrich Alexander University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (F.M.); (M.L.); (F.S.); (S.K.); (G.F.W.); (R.G.); (C.K.)
| | - Felix Rückert
- Department of Surgery, Medical Faculty Mannheim, University Medical Centre Mannheim, Heidelberg University, 68167 Mannheim, Germany;
| | - Thilo Welsch
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, 01307 TU Dresden, Germany; (T.W.); (M.D.)
| | - Marius Distler
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, 01307 TU Dresden, Germany; (T.W.); (M.D.)
| | - Stephan Kersting
- Department of General and Visceral Surgery, University Hospital of Friedrich Alexander University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (F.M.); (M.L.); (F.S.); (S.K.); (G.F.W.); (R.G.); (C.K.)
| | - Georg F. Weber
- Department of General and Visceral Surgery, University Hospital of Friedrich Alexander University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (F.M.); (M.L.); (F.S.); (S.K.); (G.F.W.); (R.G.); (C.K.)
| | - Robert Grützmann
- Department of General and Visceral Surgery, University Hospital of Friedrich Alexander University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (F.M.); (M.L.); (F.S.); (S.K.); (G.F.W.); (R.G.); (C.K.)
| | - Christian Krautz
- Department of General and Visceral Surgery, University Hospital of Friedrich Alexander University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (F.M.); (M.L.); (F.S.); (S.K.); (G.F.W.); (R.G.); (C.K.)
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Badal BD, Kruger AJ, Hart PA, Lara L, Papachristou GI, Mumtaz K, Hussan H, Conwell DL, Hinton A, Krishna SG. Predictors of hospital transfer and associated risks of mortality in acute pancreatitis. Pancreatology 2021; 21:25-30. [PMID: 33341342 DOI: 10.1016/j.pan.2020.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 11/03/2020] [Accepted: 12/02/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND There is limited research in prognosticators of hospital transfer in acute pancreatitis (AP). Hence, we sought to determine the predictors of hospital transfer from small/medium-sized hospitals and outcomes following transfer to large acute-care hospitals. METHODS Using the 2010-2013 Nationwide Inpatient Sample (NIS), patients ≥18 years of age with a primary diagnosis of AP were identified. Hospital size was classified using standard NIS Definitions. Multivariable analyses were performed for predictors of "transfer-out" from small/medium-sized hospitals and mortality in large acute-care hospitals. RESULTS Among 381,818 patients admitted with AP to small/medium-sized hospitals, 13,947 (4%) were transferred out to another acute-care hospital. Multivariable analysis revealed that older patients (OR = 1.04; 95%CI 1.03-1.06), men (OR = 1.15; 95%CI 1.06-1.24), lower income quartiles (OR = 1.54; 95%CI 1.35-1.76), admission to a non-teaching hospital (OR = 3.38; 95%CI 3.00-3.80), gallstone pancreatitis (OR = 3.32; 95%CI 2.90-3.79), pancreatic surgery (OR = 3.14; 95%CI 1.76-5.58), and severe AP (OR = 3.07; 95%CI 2.78-3.38) were predictors of "transfer-out". ERCP (OR = 0.53; 95%CI 0.43-0.66) and cholecystectomy (OR = 0.14; 95%CI 0.12-0.18) were associated with decreased odds of "transfer-out". Among 507,619 patients admitted with AP to large hospitals, 31,058 (6.1%) were "transferred-in" from other hospitals. The mortality rate for patients "transferred-in" was higher than those directly admitted (2.54% vs. 0.91%, p < 0.001). Multivariable analysis revealed that being "transferred-in" from other hospitals was an independent predictor of mortality (OR = 1.47; 95% CI 1.22-1.77). CONCLUSIONS Patients with AP transferred into large acute-care hospitals had a higher mortality than those directly admitted likely secondary to more severe disease. Early implementation of published clinical guidelines, triage, and prompt transfer of high-risk patients may potentially offset these negative outcomes.
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Affiliation(s)
- Bryan D Badal
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Andrew J Kruger
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Phil A Hart
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Luis Lara
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Georgious I Papachristou
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Khalid Mumtaz
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Hisham Hussan
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Darwin L Conwell
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Alice Hinton
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, OH, USA
| | - Somashekar G Krishna
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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10
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Murtha TD, Kunstman JW, Healy JM, Yoo PS, Salem RR. A Critical Appraisal of the July Effect: Evaluating Complications Following Pancreaticoduodenectomy. J Gastrointest Surg 2020; 24:2030-2036. [PMID: 31420859 DOI: 10.1007/s11605-019-04357-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 07/31/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Reports of higher rates of medical errors in the month of July have generated concern regarding major surgery at academic institutions early in the yearly promotion cycle. This study was designed to evaluate perioperative outcomes in patients undergoing pancreaticoduodenectomy (PD) at different times of the year. MATERIALS AND METHODS Outcomes were retrospectively evaluated for patients treated in July versus the rest of the year and in the first quarter (July-September) versus the remaining quarters. The primary outcome was operative morbidity as measured by Clavien-Dindo grade, a classification system of surgical complications. Secondary outcomes included mortality, operative blood loss, pancreatic fistula formation, delayed gastric emptying, intraabdominal abscess, anastomotic leak, reoperation, and other variables of interest. RESULTS From January 2003 to September 2015, 472 patients underwent PD by a single academic surgeon. Overall, 77.1% of PDs were performed for malignancy. The number of patients did not significantly vary by month or by quarter. The incidence of major morbidity (Clavien-Dindo grade ≥ III) in patients who had a PD was 12.2% in July and 17.5% in all other months (P = 0.79). The rate of pancreatic fistula, intraabdominal abscess, reoperation, readmission, and mortality did not differ significantly by month or by quarter (P > 0.05 for all). CONCLUSIONS The current study does not find any correlation between time of year and operative morbidity or mortality, suggesting that PD can be safely performed irrespective of timing.
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Affiliation(s)
- Timothy D Murtha
- Department of Surgery, Section of Surgical Oncology, Yale School of Medicine, P.O. Box 208062, New Haven, CT, 06520-8062, USA
| | - John W Kunstman
- Department of Surgery, Section of Surgical Oncology, Yale School of Medicine, P.O. Box 208062, New Haven, CT, 06520-8062, USA
| | - James M Healy
- Department of Surgery, Section of Surgical Oncology, Yale School of Medicine, P.O. Box 208062, New Haven, CT, 06520-8062, USA
| | - Peter S Yoo
- Department of Surgery, Section of Transplantation Surgery and Immunology, Yale School of Medicine, New Haven, CT, USA
| | - Ronald R Salem
- Department of Surgery, Section of Surgical Oncology, Yale School of Medicine, P.O. Box 208062, New Haven, CT, 06520-8062, USA.
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11
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Chan MQ, Balasubramanian G, Modi RM, Papachristou GI, Strobel SG, Groce JR, Hinton A, Krishna SG. Changing epidemiology of esophageal stent placement for dysphagia: a decade of trends and the impact of benign indications. Gastrointest Endosc 2020; 92:56-64.e7. [PMID: 32105711 DOI: 10.1016/j.gie.2020.02.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 02/08/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS In addition to managing malignant obstruction, esophageal stents (ESs) have evolved to address various benign etiologies of dysphagia. We sought to evaluate national trends and changes in practice of ES placement for both benign and malignant etiologies in hospitalized patients with dysphagia. METHODS The National Inpatient Sample (2003-2013) was used to include all adult inpatients (≥18 years of age) with endoscopy-guided ES placement for a symptom of dysphagia. Multivariable analyses for indications that impact temporal trends (3 time periods: 2003-2005, 2006-2009, and 2010-2013) and for hospital outcomes were performed. RESULTS A total of 7198 ESs were deployed endoscopically in hospitalized patients with dysphagia. Compared with malignant etiologies, there was a significant increase in ES placement for benign conditions (2013 vs 2003: 32.7% vs 14.5%, respectively; P < .001). Multivariable analysis using 2003 to 2005 as a reference showed that patients with benign etiologies for dysphagia predominantly contributed to the increase of ES placement during the most recent time period (2010-2013: odds ratio, 2.09; 95% confidence interval, 1.40-3.13). Multivariable analysis of hospital outcomes revealed no differences in inpatient mortality, duration of hospital stay, and hospital costs between malignant and benign indications. CONCLUSIONS In the preceding decade, ES placement for hospitalized patients with dysphagia has increased, driven largely by an over 8-fold rise in stent placement for benign indications. These findings warrant continued efforts to improve stent technology to decrease the risk of migration and review practice guidelines involving ES placement for benign etiologies.
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Affiliation(s)
- Megan Q Chan
- Division of Gastroenterology, Hepatology, and Nutrition, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Gokulakishnan Balasubramanian
- Division of Gastroenterology, Hepatology, and Nutrition, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Rohan M Modi
- Division of Gastroenterology, Hepatology, and Nutrition, University of Virginia, Charlottesville, Virginia, USA
| | - Georgios I Papachristou
- Division of Gastroenterology, Hepatology, and Nutrition, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Sebastian G Strobel
- Division of Gastroenterology, Hepatology, and Nutrition, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Jeffery R Groce
- Division of Gastroenterology, Hepatology, and Nutrition, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
| | - Alice Hinton
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, Ohio, USA
| | - Somashekar G Krishna
- Division of Gastroenterology, Hepatology, and Nutrition, Wexner Medical Center, The Ohio State University, Columbus, Ohio, USA
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12
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Wegner RE, Verma V, Hasan S, Schiffman S, Thakkar S, Horne ZD, Kulkarni A, Williams HK, Monga D, Finley G, Kirichenko AV. Incidence and risk factors for post-operative mortality, hospitalization, and readmission rates following pancreatic cancer resection. J Gastrointest Oncol 2019; 10:1080-1093. [PMID: 31949925 DOI: 10.21037/jgo.2019.09.01] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background The only potentially curative approach for pancreatic cancer is surgical resection, but this technically challenging procedure carries risks for postoperative morbidities and mortality. This study of a large, contemporary national database illustrates incidences of, and risk factors for, post-procedural mortality, prolonged hospital stay, and 30-day readmission. Methods From the National Cancer Database (NCDB), stage I-III pancreatic adenocarcinomas were identified [2004-2015]. Surgical techniques included pancreaticoduodenectomy, partial pancreatectomy (selective removal of the pancreatic body/tail), total pancreatectomy (removal of the entire pancreas) with or without subtotal resection of the duodenum and/or stomach, and extended pancreatectomy. Predictors of 30/90-day post-operative mortality, 30-day readmission rates, and prolonged hospital stay (>17 days per receiver operating curve analysis) were identified via multivariable logistic regression. Results Overall, 24,798 patients were analyzed (median age of 66). The majority of cases were T3 (47%), N0 (65%), pancreatic head lesions (83%), and treated with pancreaticoduodenectomy (57%). Only 16% received neoadjuvant therapy. Overall unadjusted risk of 30- and 90-day mortality ranged from 1.3-2.5% and 4.1-7.1%, respectively, depending on extent of surgery. Independent predictors of 30-/90-day mortality included preoperative therapy, increasing age, higher comorbidity score, lower income, case volume, and more extensive surgery. Similar findings were demonstrated regarding prolonged hospital stay and 30-day readmission. Age ≥70 was most associated with 30-day mortality, whereas age ≥60 was most associated with 90-day mortality and prolonged hospital stay. Conclusions Quantitation of incidences and risk factors for postoperative outcomes following resection for pancreatic cancer is essential for judicious patient selection and shared decision-making between providers and patients.
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Affiliation(s)
- Rodney E Wegner
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Vivek Verma
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Shaakir Hasan
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Suzanne Schiffman
- Division of Surgical Oncology, Allegheny Health Network, Pittsburgh, PA, USA
| | - Shyam Thakkar
- Division of Gastroenterology, Allegheny Health Network, Pittsburgh, PA, USA
| | - Zachary D Horne
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Abhijit Kulkarni
- Division of Gastroenterology, Allegheny Health Network, Pittsburgh, PA, USA
| | - H Kenneth Williams
- Division of Surgical Oncology, Allegheny Health Network, Pittsburgh, PA, USA
| | - Dulabh Monga
- Division of Medical Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Gene Finley
- Division of Medical Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Alexander V Kirichenko
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
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13
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Chang SH. One hundred sixty pancreaticoduodenectomies for periampullary cancers in a growing-volume setting: a single-institution and a single-surgeon's experience. Ann Surg Treat Res 2019; 97:130-135. [PMID: 31508393 PMCID: PMC6722292 DOI: 10.4174/astr.2019.97.3.130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 06/07/2019] [Accepted: 07/10/2019] [Indexed: 11/30/2022] Open
Abstract
Purpose Many studies have concluded that cancer patients may have better outcomes when their surgery is performed in high-volume centers, especially when the procedure is pancreaticoduodenectomy (PD). However, some studies concluded that experienced surgeons or incorporation of expertise from high-volume centers may achieve satisfactory outcomes after PD in low-volume centers. Methods I retrospectively collected and analyzed the outcomes of PD for periampullary cancers treated with curative intent in my center. Results From August 2, 2005 to December 10, 2018, 160 pancreatic resections were done with curative intent in my center. The number of operations per year was 1 in 2005 and gradually increased to 21 in 2018. Thirty-day mortality was 0, and 90-day mortality was 1 (0.6%). Morbidity was found in 65 cases (40.6%). The median follow-up period was 23.2 months and 5-year survival rates were 28.5% for pancreas head cancer, 48.2% for distal CBD cancer, and 72.6% for AOV cancer. I divided patients into 2 groups by the number of annual operations, which is more than 21 per 2 years. The 2 groups showed no differences in terms of morbidity and mortality. Conclusion A well-trained low-volume surgeon may perform PD safely at a well-equipped low-volume center.
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Affiliation(s)
- Seong-Hwan Chang
- Department of Surgery, Konkuk University School of Medicine, Seoul, Korea
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14
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Analysis of risk factors for hemorrhage and related outcome after pancreatoduodenectomy in an intermediate-volume center. Updates Surg 2019; 71:659-667. [PMID: 31376077 DOI: 10.1007/s13304-019-00673-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 07/27/2019] [Indexed: 02/06/2023]
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15
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Sabesan A, Gough BL, Anderson C, Abdel-Misih R, Petrelli NJ, Bennett JJ. High volume pancreaticoduodenectomy performed at an academic community cancer center. Am J Surg 2018; 218:349-354. [PMID: 30389119 DOI: 10.1016/j.amjsurg.2018.10.041] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 09/22/2018] [Accepted: 10/24/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND We sought to evaluate the post-operative outcomes of patients undergoing pancreaticoduodenectomy at a high volume academic community cancer center. METHODS A retrospective review was performed of patients undergoing pancreaticoduodenectomy over a 10-year period. RESULTS Over 10 years, 213 patients underwent pancreaticoduodenectomy. Median age was 66y. Most patients had significant comorbidities (median ASA = 3) and were overweight (median BMI = 27). Median operative time and blood loss were 253 min and 500 ml, respectively. 160 (75%) out of 213 patients had a malignant lesion on final pathology. 121 (76%) out of 160 had R0 resection. Median lymph nodes harvested was 13. Overall incidence of DGE was 31% (67/213), with clinically significant DGE in 15% (32/213). Pancreatic leak rate was 18% (37/213), with clinically significant leaks in 10% (21/213). Median length of stay was 8 days. Grade 3/4 morbidity rate was 21% (44/206), and 30-day mortality was 2% (5/213). CONCLUSIONS At a high volume academic community cancer center, pancreaticoduodenectomy can be performed with excellent outcomes on par with any academic center or university hospital.
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Affiliation(s)
- Arvind Sabesan
- Helen F. Graham Cancer Center & Research Institute at Christiana Care Health System, Department of Surgery, 4701 Ogletown-Stanton Road Suite 4000, Newark, DE, USA, 19713.
| | - Benjamin L Gough
- Helen F. Graham Cancer Center & Research Institute at Christiana Care Health System, Department of Surgery, 4701 Ogletown-Stanton Road Suite 4000, Newark, DE, USA, 19713.
| | - Carinne Anderson
- Helen F. Graham Cancer Center & Research Institute at Christiana Care Health System, Department of Surgery, 4701 Ogletown-Stanton Road Suite 4000, Newark, DE, USA, 19713.
| | - Raafat Abdel-Misih
- Helen F. Graham Cancer Center & Research Institute at Christiana Care Health System, Department of Surgery, 4701 Ogletown-Stanton Road Suite 4000, Newark, DE, USA, 19713.
| | - Nicholas J Petrelli
- Helen F. Graham Cancer Center & Research Institute at Christiana Care Health System, Department of Surgery, 4701 Ogletown-Stanton Road Suite 4000, Newark, DE, USA, 19713.
| | - Joseph J Bennett
- Helen F. Graham Cancer Center & Research Institute at Christiana Care Health System, Department of Surgery, 4701 Ogletown-Stanton Road Suite 4000, Newark, DE, USA, 19713.
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Zarzavadjian Le Bian A, Cesaretti M, Tabchouri N, Wind P, Fuks D. Late Pancreatic Anastomosis Stricture Following Pancreaticoduodenectomy: a Systematic Review. J Gastrointest Surg 2018; 22:2021-2028. [PMID: 29980974 DOI: 10.1007/s11605-018-3859-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 06/21/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND With an increasing postoperative survival and prolonged follow-up, late complications following pancreaticoduodenectomy (PD) have yet to be thoroughly described and analyzed. Among those, pancreatic anastomosis stricture may lead to severe consequences. METHODS A systematic review focusing on pancreaticojejunostomy anastomosis (PJA) stricture. RESULTS PJA stricture incidence reached 1.4-11.4% with a median time interval of 34 months after PD. No risk factor was identified. PJA stricture repercussions were inconsistent but postprandial abdominal pain and recurrent acute pancreatitis were the most common symptoms, followed by impaired pancreatic function. To confirm diagnosis, secretin-enhanced magnetic resonance cholangiopancreatography (SMRCP) sensitivity reached 56-100%. As impaired pancreatic function is not improved by any procedure, only PJA stricture leading to abdominal pain or acute pancreatitis should be considered for treatment. Endoscopic techniques (mainly ultrasound-assisted "rendezvous") should be proposed prior to surgical repair, with a morbidity, an overall technical and clinical success reaching 16.5-33% and 28.6-100% and 33-100%, respectively. Regarding surgical repair, overall morbidity varied between 14.3 and 33%, with a clinical success reaching 26.1-100%. Finally, total pancreatectomy with islet auto-transplantation should be considered only for pain intractable to medical management and recurrent acute pancreatitis which has failed medical, endoscopic, and traditional surgical management strategies. CONCLUSION PJA stricture following PD is a late, unusual, and potentially serious complication. When there is currently no clear consensus, PJA stricture leading to abdominal pain or acute pancreatitis should be considered treatment. With increasing survival after PD, further studies should focus on late complications. CORE TIP Stricture of pancraticojejunostomy is a late and potentially serious complication after pancreaticoduodenectomy. Incidence reaches 1.4-11.4% and no risk factor is identified. Symptoms are inconsistent but postprandial abdominal pain, recurrent acute pancreatitis, and impaired pancreatic function are the most frequent. To confirm diagnosis, secretin-enhanced magnetic resonance cholangiopancreatography is the best modality. Only PJA stricture leading to abdominal pain or acute pancreatitis should be considered for treatment. Endoscopic techniques (mainly ultrasound-assisted "rendezvous") should be proposed prior to surgical repair. Finally, total pancreatectomy with islet auto-transplantation should be considered only for pain intractable to medical management and recurrent acute pancreatitis which has failed medical, endoscopic, and traditional surgical management strategies.
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Affiliation(s)
- Alban Zarzavadjian Le Bian
- Department of Digestive Surgery and Surgical Oncology - Hôpital Avicenne, Assistance Publique - Hôpitaux de Paris, Université Paris XIII, 125 rue de Stalingrad, 93000, Bobigny, France.
| | - Manuela Cesaretti
- Department of Digestive Surgery, Groupe Hospitalier Paris Saint-Joseph, 185, rue Raymond Losserand, 75014, Paris, France
| | - Nicolas Tabchouri
- Department of Digestive, Oncologic and Metabolic Surgery - Institut Mutualiste Montsouris, 42 Boulevard Jourdan, 75014, Paris, France
| | - Philippe Wind
- Department of Digestive Surgery and Surgical Oncology - Hôpital Avicenne, Assistance Publique - Hôpitaux de Paris, Université Paris XIII, 125 rue de Stalingrad, 93000, Bobigny, France
| | - David Fuks
- Department of Digestive, Oncologic and Metabolic Surgery - Institut Mutualiste Montsouris, 42 Boulevard Jourdan, 75014, Paris, France.,Université Paris Descartes, 15 rue de l'Ecole de Médecine, 75006, Paris, France
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17
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Tsamalaidze L, Stauffer JA. Pancreaticoduodenectomy: minimizing the learning curve. J Vis Surg 2018; 4:64. [PMID: 29682474 DOI: 10.21037/jovs.2018.03.07] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 03/11/2018] [Indexed: 12/19/2022]
Abstract
Background Pancreaticoduodenectomy outcomes improve as surgeon experience increases. We analyzed the outcomes of pancreaticoduodenectomy for any improvements over time to assess the learning curve. Methods A retrospective study of patients undergoing consecutive pancreaticoduodenectomy by a single surgeon at the beginning of practice was performed. Operative factors and 90-day outcomes were examined and trends over the course of the 4-year time period were analyzed. Results Between July 2011 and June 2015, 124 patients underwent pancreaticoduodenectomy (including total pancreatectomy, n=17) by open (n=93) or a laparoscopic (n=31) approach. The median operative time was 305 minutes which significantly improved over time. The median blood loss and length of stay were 250 mL and 6 days respectively which did not change over time. The pancreatic fistula rate, total morbidity, major morbidity, and mortality, and readmission rate was 7.5%, 41.1%, 14.5%, 1.6%, and 15.3% respectively and did not change over time. Pancreaticoduodenectomy was performed most commonly for pancreatic adenocarcinoma (51.6%) with a negative margin rate of 91.1% which significantly improved over time. Conclusions The performance of pancreaticoduodenectomy improves as surgical experience is gained. However, a learning curve that impacts patient outcomes can be considerably diminished by appropriate training, high-volume practice/institution, proficient mentorship and experienced multidisciplinary team.
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Affiliation(s)
- Levan Tsamalaidze
- Department of Surgery, Mayo Clinic, Jacksonville, Florida, USA.,Tbilisi State Medical University, Tbilisi, Georgia
| | - John A Stauffer
- Department of Surgery, Mayo Clinic, Jacksonville, Florida, USA
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Modi RM, Mikhail S, Ciombor K, Perry KA, Hinton A, Stanich PP, Zhang C, Conwell DL, Krishna SG. Outcomes of nutritional interventions to treat dysphagia in esophageal cancer: a population-based study. Dis Esophagus 2017; 30:1-8. [PMID: 28881909 DOI: 10.1093/dote/dox101] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Indexed: 12/11/2022]
Abstract
Esophageal cancer (EC) is increasing in prevalence due to rising incidence and improved treatment strategies. Dysphagia is a significant morbidity in patients with EC requiring nutritional intervention. We sought to evaluate outcomes of nutritional interventions for EC patients hospitalized with dysphagia at a population level. The National Inpatient Sample (2002-2012) was utilized to include all adult inpatients (≥18 years of age) with EC and presence of dysphagia and stricture that underwent nutritional interventions including feeding tube (FT) placement, esophageal stenting, or parenteral nutrition (PN). Temporal trends were examined with multivariate analysis performed for mortality, length of stay (LOS), and cost of hospitalization. A total of 509,593 EC patients had 12,205 hospitalizations related to dysphagia. The hospitalization rates doubled over the study period (1.52% vs. 3.28%, p < 0.001). The most common nutritional intervention was FT (27%), followed by esophageal stenting (13%), and PN (11%). PN was more frequently associated with a diagnosis of sepsis (6.1%, p = 0.023) compared to FT (2.5%) or esophageal stenting (1.8%). Multivariate analysis demonstrated FT and esophageal stenting had comparable mortality (OR 1.06, 95% CI: 0.49, 2.32); however, PN was associated with higher mortality (OR 2.37, 95% CI: 1.22, 4.63), cost of hospitalization ($5,510, 95% CI: 2,262, 8,759), and LOS (2.13 days, 95% CI: 0.72, 3.54). This study shows that hospitalizations for EC with dysphagia and related nutritional interventions are increasing. As a single modality, parenteral nutrition should be avoided. Among our esophageal stent and FT population, further studies are necessary to determine adequate interventions based on disease stage.
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Affiliation(s)
| | | | | | - K A Perry
- Division of General and Gastrointestinal Surgery
| | - A Hinton
- Division of Gastroenterology, Hepatology and Nutrition, Wexner Medical Center
| | - P P Stanich
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, Ohio, USA
| | - C Zhang
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, Ohio, USA
| | - D L Conwell
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, Ohio, USA
| | - S G Krishna
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, Ohio, USA
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19
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Tremblay St-Germain A, Devitt KS, Kagedan DJ, Barretto B, Tung S, Gallinger S, Wei AC. The impact of a clinical pathway on patient postoperative recovery following pancreaticoduodenectomy. HPB (Oxford) 2017; 19:799-807. [PMID: 28578825 DOI: 10.1016/j.hpb.2017.04.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 03/28/2017] [Accepted: 04/29/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pancreaticoduodenectomies (PD) are complex surgical procedures. Clinical pathways (CPW) are surgical process improvement tools that guide postoperative recovery and are associated with high quality care. Our objective was to report the quality of surgical care following implementation of a CPW. METHODS We developed and implemented a CPW for patients undergoing PD at a single high volume hepato-pancreato-biliary (HPB) centre. Patient outcomes were collected prospectively during the implementation period. A comparator cohort was selected by identifying patients that underwent a PD prior to CPW development. RESULTS 122 patients underwent a PD during the CPW implementation period; 83 patients were initiated on the CPW. 74 patients underwent PD during the 12-month period prior to the CPW. The median hospital stay decreased after the implementation of the CPW (11 vs 8 days, p < 0.01) with no significant changes to mortality, morbidity, reoperation, or readmission rates. In-hospital complications were significantly higher in patients that were not initiated on the CPW (54% vs 74%, p = 0.03). CONCLUSION Results suggest the CPW reduced variability and allowed a greater proportion of patients to receive all elements of care, resulting in improved quality and efficiency of care based on current best evidence recommendations.
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Affiliation(s)
| | - Katharine S Devitt
- Department of Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Daniel J Kagedan
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Beverly Barretto
- Department of Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Stephanie Tung
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Steven Gallinger
- Department of Surgery, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; Department of Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada; Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Alice C Wei
- Department of Surgery, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada; Department of Surgery, Toronto General Hospital, University Health Network, Toronto, ON, Canada; Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada.
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Minimally invasive and open gallbladder cancer resections: 30- vs 90-day mortality. Hepatobiliary Pancreat Dis Int 2017; 16:405-411. [PMID: 28823371 DOI: 10.1016/s1499-3872(17)60025-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Accepted: 03/17/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Minimally invasive surgery is increasingly used for gallbladder cancer resection. Postoperative mortality at 30 days is low, but 90-day mortality is underreported. METHODS Using National Cancer Database (1998-2012), all resection patients were included. Thirty- and 90-day mortality rates were compared. RESULTS A total of 36 067 patients were identified, 19 139 (53%) of whom underwent resection. Median age was 71 years and 70.7% were female. Ninety-day mortality following surgical resection was 2.3-fold higher than 30-mortality (17.1% vs 7.4%). There was a statistically significant increase in 30- and 90-day mortality with poorly differentiated tumors, presence of lymphovascular invasion, tumor stage, incomplete surgical resection and low-volume centers (P<0.001 for all). Even for the 1885 patients who underwent minimally invasive resection between 2010 and 2012, the 90-day mortality was 2.8-fold higher than the 30-day mortality (12.0% vs 4.3%). CONCLUSIONS Ninety-day mortality following gallbladder cancer resection is significantly higher than 30-day mortality. Postoperative mortality is associated with tumor grade, lymphovascular invasion, tumor stage, type and completeness of surgical resection as well as type and volume of facility.
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21
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Pointer LS, Al-Qurayshi Z, Pointer DT, Kandil E, Slakey DP. Community health indicators associated with outcomes of pancreatectomy. Am J Surg 2017; 215:120-124. [PMID: 28335987 DOI: 10.1016/j.amjsurg.2017.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 01/26/2017] [Accepted: 02/05/2017] [Indexed: 12/12/2022]
Abstract
PURPOSE This study evaluates the association of environmental, social and health risk factors in relation to outcomes of pancreatic surgery. METHODS Patients who underwent pancreatectomy with a 30 day postoperative follow up in Florida, New York and Washington states were identified using the State Inpatient Databases (SID) from 2010 to 2011. This data was merged with community health indicators complied from the County Health Ranking database. Fourteen community health indicators were used to determine higher risk communities. Communities were then divided into low and high risk communities based on a scoring system using accumulative community risk. RESULTS Among 3494 patients included recipients in high-risk communities were more likely African American (p < 0.001), younger (age 40-59; p = 0.001), and had Medicaid as primary insurance (p = 0.001). Management of patients in high-risk communities was associated with increased risk of postoperative complications (p < 0.001), ICU admissions (p < 0.001), increased length of stay (p < 0.001). CONCLUSION Health indicators from patients' communities are predictors of increased risk of perioperative complications for individuals undergoing pancreas surgery.
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Affiliation(s)
- Lauren Slakey Pointer
- Department of Internal Medicine, Tulane University School of Medicine, New Orleans, LA, USA.
| | - Zaid Al-Qurayshi
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA.
| | - David Taylor Pointer
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA.
| | - Emad Kandil
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA, USA.
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Sheth SG, Conwell DL, Whitcomb DC, Alsante M, Anderson MA, Barkin J, Brand R, Cote GA, Freedman SD, Gelrud A, Gorelick F, Lee LS, Morgan K, Pandol S, Singh VK, Yadav D, Mel Wilcox C, Hart PA. Academic Pancreas Centers of Excellence: Guidance from a multidisciplinary chronic pancreatitis working group at PancreasFest. Pancreatology 2017; 17:419-430. [PMID: 28268158 PMCID: PMC5525332 DOI: 10.1016/j.pan.2017.02.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 02/22/2017] [Accepted: 02/26/2017] [Indexed: 12/11/2022]
Abstract
Chronic pancreatitis (CP) is a progressive inflammatory disease, which leads to loss of pancreatic function and other disease-related morbidities. A group of academic physicians and scientists developed comprehensive guidance statements regarding the management of CP that include its epidemiology, diagnosis, medical treatment, surgical treatment, and screening. The statements were developed through literature review, deliberation, and consensus opinion. These statements were ultimately used to develop a conceptual framework for the multidisciplinary management of chronic pancreatitis referred to as an academic pancreas center of excellence (APCOE).
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Affiliation(s)
- Sunil G. Sheth
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Darwin L. Conwell
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - David C. Whitcomb
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh and UPMC, Pittsburgh, PA, United States
| | | | - Michelle A. Anderson
- Division of Gastroenterology, University of Michigan Hospital and Health Systems, Ann Arbor, MI, United States
| | - Jamie Barkin
- University of Miami, Miller School of Medicine, Miami, FL, United States
| | - Randall Brand
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh and UPMC, Pittsburgh, PA, United States
| | - Gregory A. Cote
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC, United States
| | - Steven D. Freedman
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Andres Gelrud
- Center for Endoscopic Research and Therapeutics, University of Chicago, Chicago, IL, United States
| | - Fred Gorelick
- Section of Digestive Diseases, Yale University and VA Healthcare, West Haven, CT, United States
| | - Linda S. Lee
- Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women’s Hospital, Boston, MA, United States
| | - Katherine Morgan
- Division of Gastrointestinal and Laparoscopic Surgery, Medical University of South Carolina, Charleston, SC, United States
| | - Stephen Pandol
- Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Vikesh K. Singh
- Division of Gastroenterology, Johns Hopkins Medical Institutions, Baltimore, MD, United States
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh and UPMC, Pittsburgh, PA, United States
| | - C. Mel Wilcox
- Division of Gastroenterology, University of Alabama, Birmingham, AL, United States
| | - Phil A. Hart
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, United States,Corresponding author. Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, 410 West Tenth Avenue, Columbus, OH 43210, United States., (P.A. Hart)
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23
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The feasibility of laparoscopic pancreaticoduodenectomy—a stepwise procedure and learning curve. Langenbecks Arch Surg 2016; 402:853-861. [DOI: 10.1007/s00423-016-1541-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 12/09/2016] [Indexed: 02/06/2023]
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Achieving good perioperative outcomes after pancreaticoduodenectomy in a low-volume setting: a 25-year experience. Int Surg 2016; 100:705-11. [PMID: 25875555 DOI: 10.9738/intsurg-d-14-00176.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Perioperative mortality following pancreaticoduodenectomy has improved over time and is lower than 5% in selected high-volume centers. Based on several large literature series on pancreaticoduodenectomy from high-volume centers, some defend that high annual volumes are necessary for good outcomes after pancreaticoduodenectomy. We report here the outcomes of a low annual volume pancreaticoduodenectomy series after incorporating technical expertise from a high-volume center. We included all patients who underwent pancreaticoduodenectomy performed by a single surgeon (ADC.) as treatment for periampullary malignancies from 1981 to 2005. Outcomes of this series were compared to those of 3 high-volume literature series. Additionally, outcomes for first 10 cases in the present series were compared to those of all 37 remaining cases in this series. A total of 47 pancreaticoduodenectomies were performed over a 25-year period. Overall in-hospital mortality was 2 cases (4.3%), and morbidity occurred in 23 patients (48.9%). Both mortality and morbidity were similar to those of each of the three high-volume center comparison series. Comparison of the outcomes for the first 10 to the remaining 37 cases in this series revealed that the latter 37 cases had inferior mortality (20% versus 0%; P = 0.042), less tumor-positive margins (50 versus 13.5%; P = 0.024), less use of intraoperative blood transfusions (90% versus 32.4%; P = 0.003), and tendency to a shorter length of in-hospital stay (20 versus 15.8 days; P = 0.053). Accumulation of surgical experience and incorporation of expertise from high-volume centers may enable achieving satisfactory outcomes after pancreaticoduodenectomy in low-volume settings whenever referral to a high-volume center is limited.
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25
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Alluri RK, Leland H, Heckmann N. Surgical research using national databases. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:393. [PMID: 27867945 DOI: 10.21037/atm.2016.10.49] [Citation(s) in RCA: 204] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Recent changes in healthcare and advances in technology have increased the use of large-volume national databases in surgical research. These databases have been used to develop perioperative risk stratification tools, assess postoperative complications, calculate costs, and investigate numerous other topics across multiple surgical specialties. The results of these studies contain variable information but are subject to unique limitations. The use of large-volume national databases is increasing in popularity, and thorough understanding of these databases will allow for a more sophisticated and better educated interpretation of studies that utilize such databases. This review will highlight the composition, strengths, and weaknesses of commonly used national databases in surgical research.
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Affiliation(s)
- Ram K Alluri
- Department of Orthopaedic Surgery, Keck Medical Center of University of Southern California, Los Angeles, CA 90033, USA
| | - Hyuma Leland
- Department of Plastic Surgery, Keck Medical Center of University of Southern California, Los Angeles, CA 90033, USA
| | - Nathanael Heckmann
- Department of Orthopaedic Surgery, Keck Medical Center of University of Southern California, Los Angeles, CA 90033, USA
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Shah OJ, Singh M, Lattoo MR, Bangri SA. Pancreaticoduodenectomy: A study from India on the impact of evolution from a low to a high volume unit. World J Gastrointest Surg 2016; 8:583-9. [PMID: 27648163 PMCID: PMC5003938 DOI: 10.4240/wjgs.v8.i8.583] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Revised: 04/20/2016] [Accepted: 05/17/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To analyse the impact of turning of our department from a low to a high volume provider of pancreaticoduodenectomy (PD) on surgical outcome. METHODS A retrospective collection of data was done for patients who underwent PD. According to the number of PDs undertaken per year, we categorized the volume into low volume (< 10 PDs/year), medium volume (10-24 PDs/year) and high volume (> 25 PDs/year) groups. RESULTS From 2002 to 2013, 200 patients underwent PD. The annual number of PD increased from 4 in 2002 to 34 in 2013. The mean operative time, operative blood loss and need for intraoperative blood transfusion decreased considerably over the volume categories (P < 0.001, P < 0.001 and P < 0.001, respectively). Increased procedural volume was associated with a lower morbidity (P = 0.021) and shorter length of hospital stay (P < 0.001). Similarly the rate of mortality dropped from 10% for the low volume group to 2.2% for the medium volume group and 0.0% for the high volume group (P = 0.007). CONCLUSION The transformation from a low volume to a high volume provider of PD resulted in most favourable outcomes favouring the continued centralization of this high risk procedure.
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Ricciardiello L, Ahnen DJ, Lynch PM. Chemoprevention of hereditary colon cancers: time for new strategies. Nat Rev Gastroenterol Hepatol 2016; 13:352-61. [PMID: 27095653 DOI: 10.1038/nrgastro.2016.56] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Colorectal cancer (CRC) is potentially preventable. Chemoprevention, a focus of research for the past three decades, aims to prevent or delay the onset of cancer through the regression or prevention of colonic adenomas. Ideal pharmacological agents for chemoprevention should be cheap and nontoxic. Although data indicate that aspirin can reduce the risk of CRC in the general population, the highest return from chemopreventive strategies would be expected in patients with the highest risk of developing the disease, particularly those with a defined hereditary predisposition. Despite compelling data showing that a large number of chemopreventive agents show promise in preclinical CRC models, clinical studies have yielded conflicting results. This Review provides a historical and methodological perspective of chemoprevention in familial adenomatous polyposis and Lynch syndrome, and summarizes the current status of CRC chemoprevention in humans. Our goal is to critically focus on important issues of trial design, with particular attention on the choice of appropriate trial end points, how such end points should be measured, and which patients are the ideal candidates to be included in a chemopreventive trial.
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Affiliation(s)
- Luigi Ricciardiello
- Department of Medical and Surgical Sciences, University of Bologna, Via Massarenti 9, Bologna 40124, Italy
| | - Dennis J Ahnen
- Department of Medicine, University of Colorado School of Medicine and Gastroenterology of the Rockies, 5001 E 17th Avenue Parkway, Denver, Colorado 80220, USA
| | - Patrick M Lynch
- Department of Gastroenterology, Hepatology and Nutrition, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas 77054, USA
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28
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Delitto D, Black BS, Cunningham HB, Sliesoraitis S, Lu X, Liu C, Sarosi GA, Thomas RM, Trevino JG, Hughes SJ, George TJ, Behrns KE. Standardization of surgical care in a high-volume center improves survival in resected pancreatic head cancer. Am J Surg 2016; 212:195-201.e1. [PMID: 27260793 DOI: 10.1016/j.amjsurg.2016.03.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 02/27/2016] [Accepted: 03/01/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Durable clinical gains in surgical care are frequently reliant on well-developed standardization of practices. We hypothesized that the standardization of surgical management would result in improved long-term survival in pancreatic cancer. METHODS Seventy-seven consecutive, eligible patients representing all patients who underwent pancreaticoduodenectomy and received comprehensive, long-term postoperative care at the University of Florida were analyzed. Patients were divided into prestandardization and poststandardization groups based on the implementation of a pancreatic surgery partnership, or standardization program. RESULTS Standardization resulted in a reduction in median length of stay (10 vs 12 days; P = .032), as well as significant gains in disease-free survival (17 vs 11 months; P = .017) and overall survival (OS; 26 vs 16 months; P = .004). The improvement in overall survival remained significant on multivariate analysis (hazard ratio = .46, P = .005). CONCLUSIONS Standardization of surgical management of pancreatic cancer was associated with significant gains in long-term survival. These results suggest strongly that management of pancreatic head adenocarcinoma be standardized likely by regionalization of care at high performing oncologic surgery programs.
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Affiliation(s)
- Daniel Delitto
- Department of Surgery, College of Medicine, University of Florida Health Science Center, P.O. Box 100286, Gainesville, FL 32610, USA
| | - Brian S Black
- Department of Surgery, College of Medicine, University of Florida Health Science Center, P.O. Box 100286, Gainesville, FL 32610, USA
| | - Holly B Cunningham
- Department of Surgery, College of Medicine, University of Florida Health Science Center, P.O. Box 100286, Gainesville, FL 32610, USA
| | - Sarunas Sliesoraitis
- Department of Medicine, College of Medicine, University of Florida Health Science Center, Gainesville, FL 32610, USA
| | - Xiaomin Lu
- Department of Biostatistics & Children's Oncology Group, College of Public Health and Health Professions, University of Florida Health Science Center, Gainesville, FL 32610, USA
| | - Chen Liu
- Department of Pathology, College of Medicine, University of Florida Health Science Center, Gainesville, FL 32610, USA
| | - George A Sarosi
- Department of Surgery, College of Medicine, University of Florida Health Science Center, P.O. Box 100286, Gainesville, FL 32610, USA; North Florida/South Georgia Veterans Health System, Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610, USA
| | - Ryan M Thomas
- Department of Surgery, College of Medicine, University of Florida Health Science Center, P.O. Box 100286, Gainesville, FL 32610, USA; North Florida/South Georgia Veterans Health System, Department of Surgery, University of Florida College of Medicine, Gainesville, FL 32610, USA
| | - Jose G Trevino
- Department of Surgery, College of Medicine, University of Florida Health Science Center, P.O. Box 100286, Gainesville, FL 32610, USA
| | - Steven J Hughes
- Department of Surgery, College of Medicine, University of Florida Health Science Center, P.O. Box 100286, Gainesville, FL 32610, USA
| | - Thomas J George
- Department of Medicine, College of Medicine, University of Florida Health Science Center, Gainesville, FL 32610, USA
| | - Kevin E Behrns
- Department of Surgery, College of Medicine, University of Florida Health Science Center, P.O. Box 100286, Gainesville, FL 32610, USA.
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Loehrer AP, Chang DC, Hutter MM, Song Z, Lillemoe KD, Warshaw AL, Ferrone CR. Health Insurance Expansion and Treatment of Pancreatic Cancer: Does Increased Access Lead to Improved Care? J Am Coll Surg 2015; 221:1015-22. [PMID: 26611798 DOI: 10.1016/j.jamcollsurg.2015.09.010] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 09/09/2015] [Accepted: 09/10/2015] [Indexed: 01/05/2023]
Abstract
BACKGROUND Pancreatic cancer is increasingly common and poised to become the second leading cause of cancer deaths by the year 2020. Surgical resection is the only chance for cure, yet significant disparities in resection rates exist by insurance status. The 2006 Massachusetts health care reform serves as natural experiment to evaluate the unknown impact of health insurance expansion on treatment of pancreatic cancer. STUDY DESIGN Using the Agency for Healthcare Research and Quality's State Inpatient Databases, this cohort study examines nonelderly, adult patients with no insurance, private coverage, or government-subsidized insurance plans, who were admitted with pancreatic cancer in Massachusetts and 3 control states. The primary end point was change in pancreatic resection rates. Difference-in-difference models were used to show the impact of Massachusetts health care reform on resection rates for pancreatic cancer, controlling for confounding factors and secular trends. RESULTS Before the Massachusetts reform, government-subsidized and self-pay patients had significantly lower rates of resection than privately insured patients. The 2006 Massachusetts health reform was associated with a 15% increased rate of admission with pancreatic cancer (p = 0.043) and a 67% increased rate of surgical resection (p = 0.043) compared with control states. Measured disparities in likelihood of resection by insurance status decreased in Massachusetts and remained unchanged in control states. CONCLUSIONS The 2006 Massachusetts health care reform was associated with increased resection rates for pancreatic cancer compared with control states. Our findings provide hopeful evidence that increased insurance coverage can help improve equity in pancreatic cancer treatment. Additional studies are needed to evaluate the longevity of these findings and generalizability in other states.
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Affiliation(s)
- Andrew P Loehrer
- Department of Surgery, Massachusetts General Hospital, Boston, MA.
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Matthew M Hutter
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Zirui Song
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Keith D Lillemoe
- Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Andrew L Warshaw
- Department of Surgery, Massachusetts General Hospital, Boston, MA
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Healy MA, Krell RW, Abdelsattar ZM, McCahill LE, Kwon D, Frankel TL, Hendren S, Campbell DA, Wong SL. Pancreatic Resection Results in a Statewide Surgical Collaborative. Ann Surg Oncol 2015; 22:2468-74. [PMID: 25820999 PMCID: PMC4792252 DOI: 10.1245/s10434-015-4529-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND A strong relationship between hospital caseload and adverse outcomes has been demonstrated for pancreatic resections. Participation in regional surgical collaboratives may mitigate this phenomenon. This study sought to investigate changes over time in adverse outcomes after pancreatectomy across hospitals with different caseloads in a statewide surgical collaborative. METHODS The study investigated patients undergoing pancreatic resection from January 2008 to August 2013 at Michigan Surgical Quality Collaborative (MSQC) hospitals (1007 patients in 19 academic and community hospitals). Risk-adjusted rates of major complications, mortality, and failure to rescue were compared between hospitals based on caseloads (low, medium, and high) in early (2008-2010) and later (2011-2013) periods. Finally, the degree to which different complications explained changes in hospital outcome variation was assessed. RESULTS Adjusted rates of major complications and mortality decreased over time, driven largely by improvements at low-caseload hospitals. In 2008-2010, risk-adjusted major complication rates were higher for low-caseload than for high-caseload hospitals (27.8 vs. 17.8 %; p = 0.02). However, these differences were attenuated in 2011-2013 (22.2 vs. 20.0 %; p = 0.74). Similarly, adjusted mortality rates were higher in low-caseload hospitals in 2008-2010 (6.2 vs. 0.8 %; p = 0.02), but these differences were attenuated in 2011-2013 (3.3 vs. 1.1 %; p = 0.18). Variation in major complications decreased, largely due to decreased variation in "medical" complication rates, with less change in surgical-site complications. CONCLUSION Participation in regional quality collaboratives by lower-volume hospitals can attenuate the volume-outcome relationship for pancreatic surgery. Continued work in collaboratives with an emphasis on technical and intraoperative aspects of care may improve overall quality of care.
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Affiliation(s)
- Mark A. Healy
- Department of Surgery, Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, MI
| | - Robert W. Krell
- Department of Surgery, Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, MI
| | - Zaid M. Abdelsattar
- Department of Surgery, Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, MI
| | | | - David Kwon
- Department of Surgery, Henry Ford Health System, Detroit, MI
| | - Timothy L. Frankel
- Department of Surgery, Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, MI
| | - Samantha Hendren
- Department of Surgery, Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, MI
| | - Darrell A. Campbell
- Department of Surgery, Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, MI
| | - Sandra L. Wong
- Department of Surgery, Center for Healthcare Outcomes & Policy, University of Michigan, Ann Arbor, MI
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Eslami MH, Rybin D, Doros G, McPhee JT, Farber A. Mortality of acute mesenteric ischemia remains unchanged despite significant increase in utilization of endovascular techniques. Vascular 2015; 24:44-52. [DOI: 10.1177/1708538115577730] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Introduction In this study, we evaluated if increase in utilization of endovascular surgery has affected in-hospital mortality rates among patients with acute mesenteric ischemia. Methods The National Inpatient Sample (2003–2011) was queried for acute mesenteric ischemia using ICD-9 code for acute mesenteric ischemia (557.1). This cohort was divided into patients treated with open vascular surgery (open vascular group) and by endovascular therapies (endovascular group) based on the ICD-9CM procedure codes. Multivariable logistic regression was used to determine temporal trend for mortality while adjusting for confounding variables. Results There was 1.45-fold increase in utilization of endovascular techniques in this study. In-hospital mortality rate, total median charges and length of stay were significantly lower among the endovascular group than the open vascular group despite having significantly higher Elixhauser comorbidities index (3 ± 0.1 vs. 2.7 ± 0.1, p = .003). Over the course of the study period, there was no change in the overall mortality rate despite higher endovascular utilization. Factors associated with increased mortality included age, open surgical repair (Odds ratio: 1.45, 95% Confidence Interval: 1.10–1.91, p = .016) and bowel resection Odds ratio: 2.88, 95% Confidence Interval: 2.01–4.12). Conclusion The mortality rate for acute mesenteric ischemia remains unchanged throughout this contemporary study. Open surgical intervention, bowel resection and age were associated with increased mortality. Endovascular group patients had better survival despite higher morbidity indices.
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Affiliation(s)
- Mohammad H Eslami
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston, MA, USA
| | - Denis Rybin
- Department of Biostatistics, Boston School of Public Health, Boston, MA, USA
| | - Gheorghe Doros
- Department of Biostatistics, Boston School of Public Health, Boston, MA, USA
| | - James T McPhee
- Division of Vascular Surgery, Boston VA Medical Center, West Roxbury, MA, USA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston, MA, USA
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Eslami MH, Rybin D, Doros G, Farber A. Care of patients undergoing vascular surgery at safety net public hospitals is associated with higher cost but similar mortality to nonsafety net hospitals. J Vasc Surg 2014; 60:1627-34. [DOI: 10.1016/j.jvs.2014.08.055] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 08/02/2014] [Indexed: 11/30/2022]
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Swanson RS, Pezzi CM, Mallin K, Loomis AM, Winchester DP. The 90-day mortality after pancreatectomy for cancer is double the 30-day mortality: more than 20,000 resections from the national cancer data base. Ann Surg Oncol 2014; 21:4059-67. [PMID: 25190121 DOI: 10.1245/s10434-014-4036-4] [Citation(s) in RCA: 136] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Operative mortality traditionally has been defined as the rate within 30 days or during the initial hospitalization, and studies that established the volume-outcome relationship for pancreatectomy used similar definitions. METHODS Pancreatectomies reported to the National Cancer Data Base (NCDB) during 2007-2010 were examined for 30- and 90-day mortality. Unadjusted mortality rates were compared by type of resection, stage, comorbidities, and average annual hospital volume. Hierarchical logistic regression models generated risk-adjusted odds ratios for 30- and 90-day mortality. RESULTS After 21,482 pancreatectomies, the unadjusted 30-day mortality rate was 3.7 % (95 % confidence interval [CI] 3.4-3.9 %), which doubled at 90 days to 7.4 % (95 % CI 7.0-7.8). The unadjusted and risk-adjusted mortality rates were higher at 30 days with increasing age, increasing stage, male gender, lower income, low hospital volume, resections other than distal pancreatectomy, Medicare or Medicaid insurance coverage, residence in a Southern census division, history of prior cancer, and multiple comorbidities. The lowest-volume hospitals (<5 per year) performed 19 % of the pancreatectomies, with a risk-adjusted odds ratios for mortality that were 4.2 times higher (95 % CI 3.1-5.8) at 30 days and remained 1.9 times higher (95 % CI 1.5-2.3) at 30-90 days compared with hospitals that had high volumes (≥40 per year). CONCLUSION Mortality rates within 90 days after pancreatic resection are double those at 30 days. The volume-outcome relationship persists in the NCDB. Reporting mortality rates 90 days after pancreatectomy is important. Hospitals should be aware of their annual volume and mortality rates 30 and 90 days after pancreatectomy and should benchmark the use of high-volume hospitals.
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Affiliation(s)
- Richard S Swanson
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
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Wormer BA, Swan RZ, Williams KB, Bradley JF, Walters AL, Augenstein VA, Martinie JB, Heniford BT. Outcomes of pancreatic debridement in acute pancreatitis: analysis of the nationwide inpatient sample from 1998 to 2010. Am J Surg 2014; 208:350-62. [PMID: 24933665 DOI: 10.1016/j.amjsurg.2013.12.030] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Revised: 11/11/2013] [Accepted: 12/11/2013] [Indexed: 12/18/2022]
Abstract
BACKGROUND The objective of this study was to perform a national review of patients with acute pancreatitis (AP) who undergo pancreatic debridement (PD) to evaluate for risk factors of in-hospital mortality. METHODS The Nationwide Inpatient Sample was used to identify patients with AP who underwent PD between 1998 and 2010. Risk factors for in-hospital mortality were assessed with multivariate logistic regression. RESULTS From 1998 to 2010, there were 585,978 nonelective admissions with AP, of which 1,783 (.3%) underwent PD. From 1998 to 2010, the incidence of PD decreased from .44% to .25% (P < .01) and PD in-hospital mortality decreased from 29.0% to 15% (P < .05). Of patients undergoing PD, independent factors associated with increased odds of mortality were increased age (odds ratio [OR] 1.04, confidence interval [CI] 1.03 to 1.05; P < .01), sepsis with organ failure (OR 1.76, CI 1.24 to 2.51; P < .01), peptic ulcer disease (OR 1.83, CI 1.02 to 3.30; P < .05), liver disease (OR 2.27, CI 1.36 to 3.78; P < .01), and renal insufficiency (OR 1.78, CI 1.14 to 2.78; P < .05). CONCLUSIONS The incidence and operative mortality of PD have decreased significantly over the last decade in the United States with higher odds of dying in patients who are older, with chronic liver, renal, or ulcer disease, and higher rates of sepsis with organ failure.
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Affiliation(s)
| | - Ryan Z Swan
- Carolinas Medical Center, Charlotte, NC, USA
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Wang L, Su AP, Zhang Y, Yang M, Yue PJ, Tian BL. Reduction of alkaline reflux gastritis and marginal ulcer by modified Braun enteroenterostomy in gastroenterologic reconstruction after pancreaticoduodenectomy. J Surg Res 2014; 189:41-7. [PMID: 24679695 DOI: 10.1016/j.jss.2014.01.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Revised: 12/12/2013] [Accepted: 01/16/2014] [Indexed: 02/05/2023]
Abstract
BACKGROUND The incidence of alkaline reflux gastritis (ARG) after pancreaticoduodenectomy (PD) is high. Although Braun enteroenterostomy (BEE) may reduce ARG, BEE may result in marginal ulcers (MUs) due to the additional anastomotic stoma. We conducted this study to compare clinical outcomes of using a modified BEE (MBEE) with traditional gastrojejunostomy (TGJ), by inducting a purse-string suture instead of an additional anastomotic stoma. MATERIALS AND METHODS All 62 patients underwent standard PD at the Department of Hepatobiliopancreatic Surgery of West China Hospital between January 1, 2008 and January 31, 2012. Demographics, perioperative and postoperative factors, and follow-up morbidity were compared in those patients who underwent MBEE (n = 32, three patients were lost to follow-up) to those who underwent TGJ (n = 30, nine patients were lost to follow-up). RESULTS Patients who underwent the MBEE experienced a decrease in total morbidity including ARG and MUs, relative to those who underwent TGJ (24.1% versus 58.3%, P = 0.011). With regard to the MBEE group, the total ARG rate was statistically significantly lower compared with the TGJ group (13.8% versus 37.5%, P = 0.046). In addition, the incidence of MUs was reduced. CONCLUSIONS In patients undergoing PD, the MBEE was safely performed with significantly more patients having reduced incidence of ARG and related sequela compared with those who underwent TGJ. These results support further study of patients undergoing gastroenterostomy after resection of the distal stomach in larger, randomized studies.
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Affiliation(s)
- Li Wang
- Department of Hepatobiliopancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - An ping Su
- Department of Hepatobiliopancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Yi Zhang
- Department of Hepatobiliopancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Min Yang
- Department of Hepatobiliopancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Peng ju Yue
- Department of Hepatobiliopancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Bo le Tian
- Department of Hepatobiliopancreatic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China.
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Gerstenhaber F, Grossman J, Lubezky N, Itzkowitz E, Nachmany I, Sever R, Ben-Haim M, Nakache R, Klausner JM, Lahat G. Pancreaticoduodenectomy in elderly adults: is it justified in terms of mortality, long-term morbidity, and quality of life? J Am Geriatr Soc 2013; 61:1351-7. [PMID: 23865843 DOI: 10.1111/jgs.12360] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To evaluate long-term morbidity, mortality, and quality of life (QoL) after pancreaticoduodenectomy (PD) in elderly adults. DESIGN Retrospective cohort study. SETTING Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel. PARTICIPANTS One hundred and sixty-eight individuals aged 70 and older who underwent PD between 1995 and 2010. MEASUREMENTS A prospective pancreatic surgery database was analyzed for postoperative morbidity; mortality; intensive care unit (ICU), hospital, and rehabilitation facility stay; and readmissions after surgery. QoL was assessed using a validated questionnaire completed 3, 6, and 12 months after surgery. RESULTS Seventy-two percent of the participants had an American Society of Anesthesiologists score of 3 or greater. There was no intraoperative death. Thirty- and 60-day postoperative mortality rates were 5.9% and 6.5%, respectively. Median ICU stay was 2 days, and median hospital stay was 22 days. Sixty-four participants (37.5%) were discharged to a rehabilitation facility. The first-year readmission rate was 31%. One- and 2-year overall survival rates were 58% and 36%, respectively. Global QoL scores 3 and 12 months after surgery were 68% and 73%, respectively. Scores were lower yet comparable with those of matched individuals undergoing laparoscopic cholecystectomy. CONCLUSION Most elderly adults with pancreatic cancer survive longer than 1 year after PD; 36% survive longer than 2 years. These individuals are likely to have acceptable long-term morbidity and overall good QoL, corresponding with their age.
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Abstract
BACKGROUND Carcinoma of the right colon invading the pancreas or duodenum is rare. Evidence of the indication, operative morbidity, and survival of en bloc pancreaticoduodenectomy and right colectomy for right colon cancer invading adjacent organs is limited. OBJECTIVE : The goal of this study was to investigate the feasibility, safety, indication, and long-term results of en bloc pancreaticoduodenectomy and right colectomy in the treatment of locally advanced right-sided colon cancer. DESIGN : This was a retrospective analysis of all inpatients undergoing en bloc pancreaticoduodenectomy and right colectomy. Detailed data of these patients were assessed by a thorough review of medical charts. SETTINGS The study was conducted using a hospital database. PATIENTS Fourteen patients who underwent en bloc pancreaticoduodenectomy and right colectomy from January 1989 through December 2011 were included in the study. MAIN OUTCOME MEASURES In-hospital complications, mortality, and survival were the primary outcomes measured. RESULTS Major postoperative complications included delayed gastric empting (n = 7), class B pancreatic fistula (n = 3), and bile leakage (n = 1). Postoperative death occurred in 2 patients. The median hospital stay was 22.5 days (range, 17.0-57.0 days). Inflammatory adhesion was confirmed by pathologic examination in only 1 patient. Eight patients (57%) did not have lymph node metastasis. The median follow-up time was 21 months (range, 4-276 months). Ten patients were alive at the time of their last scheduled follow-up. The overall survival rates were 72% at 1 year and 60% at 2 years. No patient was lost to follow-up. Three patients developed tumor recurrence. The outcomes are no worse than those of the stage-matched patients without adjacent organ involvement and are much better than those of the stage-matched patients who underwent bypass surgery and chemotherapy. LIMITATIONS The number of patients in current studies is limited. CONCLUSIONS En bloc pancreaticoduodenectomy and right colectomy can be performed safely with an acceptable morbidity and mortality rate in selected patients with locally advanced right-side colon cancer. The long-term results are promising.
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Cheng C, Duppler D, Jaremko BK. Can pancreaticoduodenectomy performed at a comprehensive community cancer center have comparable results as major tertiary center? J Gastrointest Oncol 2012; 2:143-50. [PMID: 22811844 DOI: 10.3978/j.issn.2078-6891.2011.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Accepted: 08/02/2011] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Pancreatic resection is a definitive treatment modality for pancreatic neoplasm. Pancreaticoduodenectomy (PD) is the primary procedure for tumor arising from head of pancreas. Prognosis is overwhelmingly poor despite adequate resection. We maintained a prospective database covering years 2001 to 2010. Outcome data is analyzed and compared with those from tertiary centers. METHODS Sixty-two patients with various histology were included. Pylorus preserving pancreatico-duodenectomy (PPPD), classic pancreaticoduodenectomy, and subtotal pancreatectomy were procedures performed. Three patients had portal venorrhaphy performed to obtain clinically negative margin. Forty six patients had malignancy on final pathologic analysis. RESULTS The average age of patients was 63. Mean preoperative CA19-9 for exocrine pancreatic malignancies was higher than for more benign lesions. There was a decrease in operative time during this period. Blood transfusion was uncommon. There was very few pancreatic leak among the patients. Two bile leaks were identified, one controlled with the drainage tube and the other one required repeat surgery. The primary reason for the prolonged hospitalization was gastric ileus. For patients without a gastrostomy tube, nasogastric tube was kept in until gastric ileus resolved. 30 days mortality rate was calculated at 4.8. Mean survival time during our follow up was 30.6 months. Comparing to published literature, present series' mortality, morbidity, and survival are similar. Five year survival was 39%. CONCLUSION Despite overall poor outcome for patients with pancreatic and biliary malignancies, we conclude that surgery can be performed in community hospitals with special interest in treating pancreatic disorder, offering patients equivalent survival and quality of life as those operated in tertiary centers.
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Affiliation(s)
- Charles Cheng
- Appleton Medical Center, Fox Valley Surgical Associates, Appleton, Wisconsin, USA
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Hsueh CT. Pancreatic cancer: current standards, research updates and future directions. J Gastrointest Oncol 2012; 2:123-5. [PMID: 22811841 DOI: 10.3978/j.issn.2078-6891.2011.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2011] [Accepted: 08/15/2011] [Indexed: 01/05/2023] Open
Affiliation(s)
- Chung-Tsen Hsueh
- Division of Medical Oncology and Hematology, Loma Linda University Medical Center, Loma Linda, California, USA
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Kim CG, Jo S, Kim JS. Impact of surgical volume on nationwide hospital mortality after pancreaticoduodenectomy. World J Gastroenterol 2012; 18:4175-81. [PMID: 22919251 PMCID: PMC3422799 DOI: 10.3748/wjg.v18.i31.4175] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Revised: 04/25/2012] [Accepted: 05/12/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the impact of surgical volume on nationwide hospital mortality after pancreaticoduodenectomy (PD) for periampullary tumors in South Korea.
METHODS: Periampullary cancer patients who underwent PD between 2005 and 2008 were analyzed from the database of the Health Insurance Review and Assessment Service of South Korea. A total of 126 hospitals were divided into 5 categories, each similar in terms of surgical volume for each category. We used hospital mortality as a quality indicator, which was defined as death during the hospital stay for PD, and calculated adjusted mortality through multivariate logistic models using several confounder variables.
RESULTS: A total of eligible 4975 patients were enrolled in this study. Average annual surgical volume of hospitals was markedly varied, ranging from 215 PDs in the very-high-volume hospital to < 10 PDs in the very-low-volume hospitals. Admission route, type of medical security, and type of operation were significantly different by surgical volume. The overall hospital mortality was 2.1% and the observed hospital mortality by surgical volume showed statistical difference. Surgical volume, age, and type of operation were independent risk factors for hospital death, and adjusted hospital mortality showed a similar difference between hospitals with observed mortality. The result of the Hosmer-Lemeshow test was 5.76 (P = 0.674), indicating an acceptable appropriateness of our regression model.
CONCLUSION: The higher-volume hospitals showed lower hospital mortality than the lower-volume hospitals after PD in South Korea, which were clarified through the nationwide database.
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Hari M, Rosenzweig M. Incidence of Preventable Postoperative Readmissions Following Pancreaticoduodenectomy: Implications for Patient Education. Oncol Nurs Forum 2012; 39:408-12. [DOI: 10.1188/12.onf.408-412] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Effect of surgeon volume on outcome following pancreaticoduodenectomy in a high-volume hospital. J Gastrointest Surg 2012; 16:518-23. [PMID: 22083531 DOI: 10.1007/s11605-011-1777-2] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2011] [Accepted: 10/31/2011] [Indexed: 01/31/2023]
Abstract
BACKGROUND Despite the close relationship between hospital volume and mortality after pancreaticoduodenectomy (PD), the role of surgeon volume still remains an open issue. Retrospective multi-institutional reviews considered only in-hospital mortality, whereas no data about major complications are available so far. The aim of this study is to assess the independent impact of surgeon volume on outcome after PD in a single high-volume institution. METHODS Demographics and clinical and surgical variables were prospectively collected on 610 patients who underwent PD from August 2001 to August 2009. The cutoff value to categorize high- and low-volume surgeons (HVS and LVS, respectively) was 12 PD/year. The primary endpoint was operative mortality (death within 30-day post-discharge). Secondary endpoints were morbidity, pancreatic fistula (PF), and length of hospital stay (LOS). RESULTS In the whole series, mortality was 4.1%, overall morbidity was 61.3%, and PF rate was 27.5%. Two HVS performed 358 PD (58.6%), while six LVS performed 252 PD (41.4%). Mortality was 3.9% for HVS and 4.3% for LVS (p=0.84). The major complication rate was similar for HVS and LVS (14.5% vs. 16.2%). The PF rate was higher for LVS (32.4% vs. 24.1%, p=0.03). The mean LOS was 15.5 days for HVS vs. 16.9 days for LVS (p=0.11). At multivariate analysis, risk factors for PF occurrence were LVS, soft pancreatic stump, small duct diameter, and longer operative time. CONCLUSION Low-volume surgeons had a higher PF rate. However, this did not increase mortality and major morbidity rates probably because of the protective effect of high-volume hospital in improving patient rescue from life-threatening complications.
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Zenilman ME, Chow WB, Ko CY, Ibrahim AM, Makary MA, Lagoo-Deenadayalan S, Dardik A, Boyd CA, Riall TS, Sosa JA, Tummel E, Gould LJ, Segev DL, Berger JC. New developments in geriatric surgery. Curr Probl Surg 2011; 48:670-754. [PMID: 21907843 DOI: 10.1067/j.cpsurg.2011.06.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Zhang J, Zhu X, Chen H, Qian HG, Leng JH, Qiu H, Wu JH, Liu BN, Liu Q, Lv A, Li YJ, Zhou GQ, Hao CY. Management of delayed post-pancreaticoduodenectomy arterial bleeding: interventional radiological treatment first. Pancreatology 2011; 11:455-63. [PMID: 21968388 DOI: 10.1159/000331456] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Accepted: 07/27/2011] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To investigate the diagnosis and treatment of delayed post-pancreaticoduodenectomy arterial bleeding (DPPAB). METHODS Records of 336 patients who underwent pancreaticoduodenectomy (PD) between January 2000 and December 2010 were retrospectively analyzed. Detailed data of patients with DPPAB were assessed by a thorough review of medical records. RESULTS 14 patients developed DPPAB. The mean time interval between the initial surgery and DPPAB was 33 days (range 7-72). Three patients experienced sentinel bleeding 5-8 days before DPPAB. All DPPAB patients had intra-abdominal septic complications before bleeding. The overall prevalence of success of angiography and transcatheter arterial embolization (TAE) was 85.7% (12/14), including 3 patients who achieved complete hemostasis by TAE after unsuccessful re-laparotomy. The prevalence of mortality of DPPAB was 28.6% (4/14). After hemostasis was achieved, intra-abdominal septic complications were controlled by percutaneous catheter drainage or re-laparotomy with drain replacement. CONCLUSION Angiography and TAE are recommended as the first-line diagnostic and treatment choice for DPPAB, respectively. Surgical intervention should be preserved to eliminate the cause of bleeding.
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Affiliation(s)
- Ji Zhang
- Department of Hepatopancreatobiliary Surgery, Peking University School of Oncology, Beijing Cancer Hospital and Institute, Beijing, PR China
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Barlow R, Price P, Reid TD, Hunt S, Clark GWB, Havard TJ, Puntis MCA, Lewis WG. Prospective multicentre randomised controlled trial of early enteral nutrition for patients undergoing major upper gastrointestinal surgical resection. Clin Nutr 2011; 30:560-6. [PMID: 21601319 DOI: 10.1016/j.clnu.2011.02.006] [Citation(s) in RCA: 112] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2010] [Revised: 01/25/2011] [Accepted: 02/23/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The evidence in support of Early Enteral Nutrition (EEN) after upper gastrointestinal surgery is inconclusive. The aim of this study was to determine if EEN improved clinical outcomes and shortened length of hospital stay. METHODS Open, prospective multicentre randomised controlled trial within a regional UK Cancer Network. One hundred and twenty-one patients with suspected operable upper gastrointestinal cancer (54 oesophageal, 38 gastric, 29 pancreatic) were studied. Patients were randomised to receive EEN (n = 64) or Control management postoperatively (nil by mouth and IV fluid, n = 57). Analysis was based on intention-to-treat and the primary outcome measure was length of hospital stay. RESULTS Operative morbidity was less common after EEN (32.8%) than Control management (50.9%, p = 0.044), due to fewer wound infections (p = 0.017), chest infections (p = 0.036) and anastomotic leaks (p = 0.055). Median length of hospital stay was 16 days (IQ = 9) after EEN compared with 19 (IQ = 11) days after Control management (p = 0.023). CONCLUSIONS EEN was associated with significantly shortened length of hospital stay and improved clinical outcomes. These findings reinforce the potential benefit of early oral nutrition in principle and as championed within enhanced recovery after surgery programmes, and such strategies deserve further research in the arena of upper GI surgery.
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Khithani A, Christian D, Lowe K, Saad AJ, Linder JD, Tarnasky P, Jeyarajah DR. Feasibility of Pancreaticoduodenectomy in a Nonuniversity Tertiary Care Center: What Are the Key Elements of Success? Am Surg 2011. [DOI: 10.1177/000313481107700511] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
It is advocated that a favorable outcome for pancreaticoduodenectomy (PD) is related to a high volume at university centers. This article examines the specific elements that allow an equivalent outcome from PD in a nonuniversity tertiary care center (NUTCC). The study was performed to: 1) evaluate the outcome of PDs done at a NUTCC; 2) study the components of the process that are required to attain success in a NUTCC; and 3) provide a new look at the volume-outcome relationships in complex surgeries in a novel nonuniversity setting. Medical records of patients who underwent PD by a single surgeon between September 2005 and August 2008 at a high-volume NUTCC were analyzed. The records were reviewed with respect to preoperative and postoperative data, 30-day mortality, morbidity, and histopathology data. A total of 122 patients underwent PD. The mean age was 68.2 years. Jaundice was the most common presenting symptom in 57 per cent (69 patients). Thirty-nine patients (32%) underwent a pylorus-preserving PD. The mean operative time was 237 minutes. The mean estimated blood loss was 480 mL. The mean length hospital stay was 13 days. Thirty-day mortality was 3.2 per cent (four patients) and overall morbidity was 49 per cent. The key factors in developing a team dedicated to the care of the patient undergoing PD are discussed. A center of excellence can be developed in a NUTCC resulting in outcomes that meet and indeed may exceed nationally reported benchmarks. The key elements to success include a team approach to the patient undergoing PD.
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Affiliation(s)
- Amit Khithani
- Cancer Center, Methodist Dallas Medical Center, Dallas, Texas
| | - Derick Christian
- Hepatopancreatobiliary Surgery, Methodist Dallas Medical Center, Dallas, Texas
| | - Kevin Lowe
- Hepatopancreatobiliary Surgery, Methodist Dallas Medical Center, Dallas, Texas
| | - A. Joe Saad
- Department of Pathology, Methodist Dallas Medical Center, Dallas, Texas
| | - Jeffrey D. Linder
- Department of Gastroenterology, Methodist Dallas Medical Center, Dallas, Texas
| | - Paul Tarnasky
- Department of Gastroenterology, Methodist Dallas Medical Center, Dallas, Texas
| | - D. Rohan Jeyarajah
- Hepatopancreatobiliary Surgery, Methodist Dallas Medical Center, Dallas, Texas
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Parra Membrives P, Díaz Gómez D, Martínez Baena D, Lorente Herce JM. [Blood glucose control and risk of progressing to a diabetic state during clinical follow up after cephalic duodenopancreatectomy]. Cir Esp 2011; 89:218-22. [PMID: 21349504 DOI: 10.1016/j.ciresp.2010.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2010] [Revised: 12/12/2010] [Accepted: 12/14/2010] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Pancreatic resection carries a theoretical risk of developing diabetes; however few studies have demonstrated the effect of a cephalic duodenopancreatectomy on post-operative blood glucose control. MATERIAL AND METHODS An analysis was made of the post-operative clinical follow up of 70 patients subjected to a cephalic duodenopancreatectomy in our Hospital between March 1993 and November 2009. The surgical indication was due to primary pancreatic disease in 30 patients (21 adenocarcinoma of the pancreas, 6 chronic pancreatitis, 1 endocrine carcinoma, 1 cystadenoma and 1 complicated pseudocyst). The pancreas was not affected in the other 40 patients (24 ampullary carcinomas, 11 cholangiocarcinomas, 3 duodenal carcinomas, 1 papillary adenoma and 1 adenomatous hyperplasia of the bile duct). Data on the pre- and post-operative diabetic state were collected. RESULTS Before resection, 49 patients (70.0%) had a normal glucose without the need for treatment. Seventeen patients required oral diabetic treatment, 3 subcutaneous insulin, and only one was treated by diet. The duodenopancreatectomy worsened glucose control in 47.1% of the patients (23 of the previously non-diabetics and 10 of those treated with oral diabetics). Glucose control was worse when the surgical indication was due to primary involvement of the gland (progression of 63.3%) compared with patients with disease (progression of 35.0%) (P<.05). CONCLUSIONS Our results show that resection of the head of the pancreas favours the appearance of post-operative diabetes, particularly when the surgical indication is due to primary pancreatic involvement.
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Affiliation(s)
- Pablo Parra Membrives
- Sección de Cirugía Hepato-bilio-pancreática, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Valme, Sevilla, España.
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Eslami MH, McPhee JT, Simons JP, Schanzer A, Messina LM. National trends in utilization and postprocedure outcomes for carotid artery revascularization 2005 to 2007. J Vasc Surg 2011; 53:307-15. [DOI: 10.1016/j.jvs.2010.08.080] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2010] [Revised: 08/26/2010] [Accepted: 08/26/2010] [Indexed: 10/18/2022]
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Nguyen LL, Barshes NR. Analysis of large databases in vascular surgery. J Vasc Surg 2010; 52:768-74. [PMID: 20598475 DOI: 10.1016/j.jvs.2010.03.027] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2010] [Revised: 03/08/2010] [Accepted: 03/15/2010] [Indexed: 10/19/2022]
Abstract
Large databases can be a rich source of clinical and administrative information on broad populations. These datasets are characterized by demographic and clinical data for over 1000 patients from multiple institutions. Since they are often collected and funded for other purposes, their use for secondary analysis increases their utility at relatively low costs. Advantages of large databases as a source include the very large numbers of available patients and their related medical information. Disadvantages include lack of detailed clinical information and absence of causal descriptions. Researchers working with large databases should also be mindful of data structure design and inherent limitations to large databases, such as treatment bias and systemic sampling errors. Withstanding these limitations, several important studies have been published in vascular care using large databases. They represent timely, "real-world" analyses of questions that may be too difficult or costly to address using prospective randomized methods. Large databases will be an increasingly important analytical resource as we focus on improving national health care efficacy in the setting of limited resources.
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Affiliation(s)
- Louis L Nguyen
- Department of Vascular Surgery, Brigham and Women's Hospital, Boston, Mass 02115, USA.
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Wouters M, Jansen-Landheer M, van de Velde C. The quality of cancer care initiative in the Netherlands. Eur J Surg Oncol 2010; 36 Suppl 1:S3-S13. [DOI: 10.1016/j.ejso.2010.06.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2010] [Accepted: 06/01/2010] [Indexed: 01/08/2023] Open
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