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

Table 1 Summary of studies comparing peri-operative mortality according to hospital volumes

Author	Peri-operative mortality		P	Study population	Definition of high volume (cases per annum)
	Low volume	High volume
Lieberman et al[2], 1995	18.9%	5.5%	< 0.001	2233 PDs over 8 years in New York, USA from 1984-1991	Minimal: < 10; Low: 10-50; High: > 50
Glasgow et al[9], 1996	14.1%	3.5%	0.0009	1424 PDs using data from the California Office of Health wide State Planning and Development from 1990-1994	I (Low): 1-5’; II: 6-10; III: 11-20; IV: 21-30; V: 31-50; VI (High): 50
Sosa et al[3], 1998	18.8%	0.9%	< 0.001	449 PDs + 47 total pancreatectomies from 48 non-federal hospitals in Maryland, USA from 1990-1995	Low: < 5; Medium: 5-19; High: > 20
Birkmeyer et al[5], 1999	16%	4%	< 0.0001	7229 PDs from the US-based Medicare database from 1992-1995	Very Low: < 1; Low: 1-2; Medium: 2-5; High: > 5
Gouma et al[12], 2000	13.2% (Cutoff III)	8.1% (Cutoff III)	NS	1126 patients from 1994–1998 from the National Medical Registry in the Netherlands	I: < 5; II: 5-10; III: 10-25; IV: > 25
Kotwall et al[6], 2002	12.6%	9%	< 0.001	24926 PDs from the US-based National Inpatient Database from 1988-1995	Low: ≤ 1; High: > 1
Nordback et al[13], 2002	13%	4%	< 0.005	350 PDs from the National Hospital Discharge Database in Finland from 1990-1994	Low: < 5; Medium: 5-10; High: > 10
Finlayson et al[14], 2003	11%	3%	< 0.001	3414 pancreatic resections (unspecified) from the US based Nationwide Medicare Database from 1994-1999	Very Low: < 1; Low: 1-2; Medium: 3-4; High: 5-13; Very High: > 13
Ho et al[7], 2003	14.6%	4.7%	< 0.0001	6709 PDs in California and Florida (from insurance claims) between 1988-1998	Very Low: 1; Low: 2-3; Medium: 4–9; High: > 10
Van Heek et al[15], 2005	11.8%	3.8%	< 0.001	Systematic review of studies reporting mortality in 1988 unspecified pancreatic resections in the Dutch Nationwide Registry from 1994-2004	Very Low: < 5; Low: 5-9; Medium: 10-24; High: > 24
Fong et al[4], 2005	8%	2%	0.001	2592 PDs across 1101 hospitals using data from national Medicare database between 1995-1996	Low Volume: ≤ 25; High Volume: > 25
McPhee et al[16], 2007	11.1%	2.7%	< 0.001	39463 pancreatic resections from the US-based National Inpatient Sample Database from 1998-2003 (27289 PDs analyzed separately)	Low: < 5; Medium: 5-18; High: > 18
Riall et al[17], 2007	7.4%	3.0%	< 0.001	3189 pancreatic resections in Texas using the Texas Hospital Inpatient Discharge Public Use Data File from 1999-2004	Low: < 10; High: > 10
Meguid et al[18], 2008	11.1%	5.22%	< 0.001	7558 pancreatic resections from the Nationwide Inpatient Sample from 1998-2003	Low: 1-18; High: > 18;
Billimora et al[8], 2008	15.4%	4.99%	< 0.001	13107 unspecified pancreatectomies in 1454 hospitals via ACS National Cancer Database from 1994-1999	Low: < 2; Medium: 2-9; High: ≥ 10
Balzano et al[19], 2008	12.4%	2.6%	< 0.0001	1576 patients (1044 PDs) from 221 hospitals in Italy using data from Ministry of Health in the year 2003	Low Volume: < 5; Medium: 6-13; High: 14-51; Very High: > 52
Gasper et al[20], 2009	Pooled estimated effects in favour of high-volume hospitals: OR 0.25 (95%CI 0.15-0.41)		< 0.01	5294 patients undergoing pancreatic resections (unspecified) between 1994-2004 from the US-based California Discharge Database	Low: < 5; Medium: 5-49; High: > 50
Teh et al[21], 2009	OR hospital mortality (95%CI) 4.0 (3.1-5.1)	OR hospital mortality (95%CI) 1.7 (1.3-2.4)	< 0.01	103222 patients (76273 PDs) from the Nationwide Inpatient Sample in USA between 1988–2003	Very Low: 3; Low: 3-5; Medium: 6-11; High: 12-23; Very High: 24-35; Extra: > 36
Nathan et al[11], 2009	33.7%	33.5%	0.56	8251 PDs from the State Inpatient Databases for Florida, Maryland, and New York from 1998-2005	Low: < 25; Mid: 25-124; High ≥ 125
Schmidt et al[1], 2010	4%	2%	= 0.04	1003 PDs at Indiana University across two periods 1980-2003 and 2004-2007	Low: < 20; High: > 20
Gooiker et al[22], 2011	Pooled estimated effects in favour of high-volume hospitals: OR 0.32 (95%CI 0.16-0.64)		< 0.001	Metanalysis of 154626 patients across 14 studies undergoing unspecified pancreatic resections from 1970-2010	Pooled volume groups as defined in individual studies; Lowest: 1-5; Highest: 7-36
La Torre et al[10], 2012	2.5%	2.1%	0.66	Systematic literature review of patients undergoing pancreatectomy across 18 studies	Low: 9-8; Medium: 9-12; High: 13-18; Very High: > 19
Alsfasser et al[23], 2012	32.2% (1-yr mortality)	26.2% (1-yr mortality)	< 0.001	9566 patients who underwent PD or total pancreatectomy in Germany from 2006-2009	Low: < 32; High: > 32
Bliss et al[24], 2014	8.1%	3.1%	< 0.001	129609 pancreatectomies from the US based Nationwide Inpatient Sample 2004–2011	Low: < 5; Medium: 5-18; High: > 18; Very High: > 50
Derogar et al[25], 2015	60% greater mortality risk	NR	HR 1.60, 1.04 to 2.48	3298 pancreatic resections from the Swedish National Register (2818 PDs not separately reported) from 1990-2010	≥ 4 (not clearly defined)
Hata et al[26], 2016	Overall pooled OR for mortality in favour of high-volume hospitals: OR 2.37 (95%CI 1.95-2.88)		0.09	Metanalysis of 58023 patients undergoing PD across 13 studies based on nationwide databases from 11 countries	Low: 1-19; Medium: 20-29; High: ≥ 30
Briceno et al[27], 2017	5.5%	2.6%	< 0.001	19024 PDs using the US based National Cancer Database from 2010-2015	Low: < 10; Medium: 10-20; High: > 20 per year
El Amrani et al[28], 2018	4.4%	3.4%	0.047	10632 patients undergoing distal pancreatectomy from 2009-2018 from a national French database	Low Volume: ≤ 10; High Volume: > 10
Krautz et al[29], 2018	10.4%	8.1%	NS	Analysis of 60858 patients undergoing major pancreatic surgery (unspecified) from a German National Database from 2009-2014	Very Low: < 8; Low: 8-18; Medium: 19-31; High: 32-58; Very High: > 59
Balzano et al[30], 2020	8.1%	4.4%	< 0.001	Multicenter study of 7631 PDs (12662 pancreatic resections) in 395 Italian hospitals from 2014-2016	Very Low: 0-10; Low: 10-25; Medium: 25-60; High: 60-166; Very High > 167

NR: Not reported; PD: Pancreatico-duodenectomy; US: United States; ACS: American College of Surgeons; HR: Hazard ratio; OR: Odds ratio; CI: Confidence intervals.

Table 2 Summary of studies comparing peri-operative mortality according to surgeon volumes

Author	Peri-operative mortality		P	Study population	Definition of low-volume surgeon	Definition of high-volume surgeon
	Low volume surgeon, %	High volume surgeon, %
Lieberman et al[2], 1995	15.5	4.7	< 0.001	2233 PDs over 8 years in New York State	< 9 cases experience	> 41 cases experience
Sosa et al[3], 1998	12	1.8	< 0.001	449 PDs + 47 total pancreatectomies from non-federal facilities in Maryland, USA	< 5 PD annually	> 50 PD annually
Nordback et al[13], 2002	14	3	< 0.05	350 PDs in 33 hospitals by 98 surgeons	< 1 annually	> 3 annually
Schmidt et al[1], 2010	4	2	0.09	1003 PDs at Indiana University across 2 periods	< 20 annually	> 20 PD annually
Eppsteiner et al[35], 2009	6.4	2.4	< 0.0001	3581 pancreatic resections from the National Inpatient Sample Database	< 5 annually	≥ 5 annually

PD: Pancreatico-duodenectomy.

Table 3 Proportion of pancreatico-duodenectomies performed outside of high-volume centers

Author	Country	PDs performed by low volume hospital, %	Average surgeon volume	Average hospital volume
Sosa et al[3], 1998	Maryland, United States	47.3	1 per year	1 per year
Riall et al[17], 2007	Texas, United States	36.7	NR	< 5 PD per year
Birkmeyer et al[5], 1999	Medicare database, United States	> 50	NR	< 2 PD per year
Ho et al[7], 2003	Florida and California, United States	77	NR	10% in hospitals doing 1 PD per year
Bliss et al[24], 2014, For period < 2004	Nationwide inpatient sample database, United States	40.8	NR	NR
Bliss et al[24], 2014, For period > 2011	Nationwide inpatient sample database, United States	26.9	NR	NR
Glasgow et al[9], 1996	California, United States	88	NR	< 2 PD per year
Fong et al[4], 2005	National Medicare Database, United States	89	1 per year	1 PD per year

PD: Pancreatico-duodenectomy; NR: Not reported.

Table 4 Patients undergoing pancreatico-duodenectomy at high-volume centers (%)

Parameter	Data source	Whites, %	Non-whites, %	P
Sosa et al[3], 1998	Non-federal facilities in Maryland, United States	25.2	9.8	< 0.001
McPhee et al[16], 2007	National Inpatient Sample Database, United States	80	20	NS
Bliss et al[24], 2014	National Inpatient Sample Database, United States	65.6	34.4	0.018
Eppsteiner et al[35], 2009	National Inpatient Sample Database, United States	79.3	20.7	NS

PD: Pancreatico-duodenectomy; NS: Not specified.

Table 5 Patients undergoing pancreatico-duodenectomy with private insurance coverage (%)

Parameter	Data source	High-volume center, %	Low-volume center, %	P
Bliss et al[24], 2014	6144 patients undergoing PD	43.7	36.9	< 0.001

PD: Pancreatico-duodenectomy.

Table 6 A comparison of outcomes in 90 patients undergoing pancreatico-duodenectomy in a Caribbean centre

Parameter	Sub-specialty surgeon, (%)	General surgeon, (%)	P
Attempted PD	72/90 (80)	18 (20)	< 0.0001Z
Completed PD	68/72 (94)	0	< 0.0001F
Portal vein resection/reconstruction	19/72 (26)	0	0.0103F

^FStatistical analysis using Fishers Exact Test.

^ZStatistical analysis using Z-test for Proportions.

PD: Pancreatico-duodenectomy.