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

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.

Keywords: Pancreas; Surgery; Pancreatectomy; Whipple’s; Pancreaticoduodenectomy

Core Tip: The published data generally support pancreaticoduodenectomies (PD) being reserved for high volume hospitals. However, this is not practical in resource-poor, low volume countries in the Caribbean. Nevertheless, we have documented good short-term outcomes after PD in this setting. In this paper we discuss a modified centralization concept used to incorporate PD into these low volume centers.