scholarly journals Centralization of Pancreatic Surgery Improves Results: Review

2020 ◽  
Vol 109 (1) ◽  
pp. 4-10 ◽  
Author(s):  
R. Ahola ◽  
J. Sand ◽  
J. Laukkarinen
Keyword(s):  
Pancreatic Surgery ◽  
Length Of Hospital Stay ◽  
High Volume ◽  
Optimal Operation ◽  
Failure To Rescue ◽  
Short Term ◽  
Pancreatic Resections ◽  
The World ◽  
Low Volume ◽  
Active Research

Background and Aims: The effect of operation volume on the outcomes of pancreatic surgery has been a subject of research since the 1990s. In several countries around the world, this has led to the centralization of pancreatic surgery. However, controversy persists as to the benefits of centralization and what the optimal operation volume for pancreatic surgery actually is. This review summarizes the data on the effect of centralization on mortality, complications, hospital facilities used, and costs regarding pancreatic surgery. Materials and Methods: A systematic librarian-assisted search was performed in PubMed covering the years from August 1999 to August 2019. All studies comparing results of open pancreatic resections from high- and low-volume centers were included. In total 44, published articles were analyzed. Results: Studies used a variety of different criteria for high-volume and low-volume centers, which hampers the evaluating of the effect of operation volume. However, mortality in high-volume centers is consistently reported to be lower than in low-volume centers. In addition, failure to rescue critically ill patients is more common in low-volume centers. Cost-effectiveness has also been evaluated in the literature. Length of hospital stay in particular has been reported to be shorter in high-volume centers than in low-volume centers. Conclusion: The effect of centralization on the outcomes of pancreatic surgery has been under active research and the beneficial effect of it is associated especially with better short-term prognosis after surgery.

Postoperative Outcomes of Elective Pancreatic Surgery in a Low-Volume Academic Surgical Clinic

2013 ◽  
Vol 6 (2) ◽  
pp. 106-111
Author(s):  
Alexander E. Julianov ◽  
Anatoli G. Karashmalakov ◽  
Ivan G. Rachkov ◽  
Yonko P. Georgiev
Keyword(s):  
Pancreatic Surgery ◽  
Postoperative Mortality ◽  
Postoperative Outcome ◽  
High Volume ◽  
Postoperative Outcomes ◽  
Benign Tumors ◽  
Pancreatic Resections ◽  
Low Volume ◽  
Age Range ◽  
Surgical Clinic

Summary According to the volume-outcome concept the postoperative outcome after major pancreatic surgery in high-volume institutions compares favorably to low- volume centers. However, it is not clear whether this is applicable to all low-volume institutions nowadays. The aim of the study was to evaluate the postoperative outcome after major elective pancreatic surgery in a low- volume academic surgical clinic. All consecutive elective major pancreatic cases operated within a 10-year period till October 2013 have been retrospectively reviewed. During the studied period, 36 patients (15 females, 21 males, mean age 54 years, age range 37-76) were scheduled for elective pancreatic surgery and underwent pancreatic resection (n=31, 18 proximal and 13 distal pancreatic resections) or complete pancreatic duct drainage procedure (n=5). Eleven patients had chronic pancreatitis and 25 patients had malignant or benign tumors. Vascular or adjacent organ resection was performed in 9 patients (29% of resections). The overall postoperative morbidity was 36% (n=13), and complications requiring re-operation occurred in 5 patients (14%). The median postoperative hospital stay was 11 days for patients without complications vs. 25 days for patients with any complication. There was no 60- day postoperative mortality or hospital readmission. Major elective pancreatic surgery can be safely performed today in a low-volume academic general surgical clinic, with postoperative outcomes similar to those reported by high-volume centers.

Minimally Invasive Approaches in Pancreatic Surgery

2018 ◽  
Author(s):  
Waseem Lutfi ◽  
Melissa E Hogg
Keyword(s):  
Minimally Invasive ◽  
Pancreatic Surgery ◽  
Standard Of Care ◽  
High Volume ◽  
Oncologic Outcomes ◽  
Short Term ◽  
Pancreatic Resections ◽  
Key Words Clinical Trials ◽  
Minimally Invasive Pancreatic Surgery

Minimally invasive approaches for pancreatic resections are being increasingly utilized at highly specialized centers. Both laparoscopic and robotic techniques appear to be associated with improved short-term outcomes such as decreased morbidity and shorter hospital stay. However, there are still concerns with regards to cost-effectiveness and technical training, which have prevented widespread dissemination of these techniques. For pancreatic surgery, both laparoscopic and robotic techniques have gained acceptance for all pancreatic resections, most notably in distal pancreatectomy where minimally invasive approaches have become the standard of care at high-volume centers. This chapter discusses the preoperative considerations and operative techniques of minimally invasive pancreatic surgery while also reviewing the current literature detailing short-term and long-term outcomes. This review contains 46 references, 6 figures, 5 tables, and 2 videos. Key Words: clinical trials, laparoscopic, minimally invasive, morbidity, mortality, oncologic outcomes, open, pancreatic cancer, robot-assisted

scholarly journals Blood Transfusions in Major Pancreatic Surgery: A 10-Year Cohort Study Including 1404 Patients Undergoing Pancreatic Resections in Finland

2018 ◽  
Vol 108 (3) ◽  
pp. 210-215 ◽  
Author(s):  
J.-P. Lammi ◽  
M. Eskelinen ◽  
J. Tuimala ◽  
J. Saarnio ◽  
T. Rantanen
Keyword(s):  
Blood Transfusion ◽  
Pancreatic Surgery ◽  
Total Pancreatectomy ◽  
Trigger Point ◽  
High Volume ◽  
Trigger Points ◽  
Red Cross ◽  
Blood Transfusions ◽  
Pancreatic Resections ◽  
Low Volume

Background: Despite guidelines on blood transfusion (TF) thresholds, there seems to be great variation in transfusion policies between hospitals and surgeons. In order to improve and unify blood transfusion policies, the Finnish Red Cross Blood Service carried out a project concerning the optimal use of blood products (Verivalmisteiden optimaalinen käyttö) between 2002 and 2011. In this study, we determined the blood transfusion trends in major pancreatic surgery in Finland. Methods: Initially, 1337 patients who underwent major pancreatic resections between 2002 and 2011 were classified into the TF+ or TF− groups. Centers were divided into high-, medium-, and low-volume centers. The blood transfusion trends and the trigger points for blood transfusions in these patients were determined. Results: There were no differences between high-, medium- and low-volume centers in blood usage, trigger points or the use of reserved blood units after pancreatoduodenectomy or total pancreatectomy. However, the trigger points were lowered significantly during the study period at high-volume centers (p = 0.003), and a better use of reserved blood units was found in high- (p < 0.001) and medium-volume (p = 0.043) centers. In addition, a better use of reserved blood units was found in high-volume centers after distal pancreatectomy (p = 0.020) Conclusion: Although only minor changes in blood transfusion trends after pancreatoduodenectomy or total pancreatectomy were found generally, the lowering of the transfusion trigger point and the best use of reserved blood units during the study period occurred in high-volume centers.

scholarly journals Center-Level Procedure Volume Does Not Predict Failure-to-Rescue After Severe Complications of Oncologic Colon and Rectal Surgery

2021 ◽  
Author(s):  
Miriam Lillo-Felipe ◽  
Rebecka Ahl Hulme ◽  
Maximilian Peter Forssten ◽  
Gary A. Bass ◽  
Yang Cao ◽  
...  
Keyword(s):  
Colorectal Cancer ◽  
Postoperative Complications ◽  
High Volume ◽  
Cancer Surgery ◽  
Colon And Rectal Surgery ◽  
Surgical Volume ◽  
Failure To Rescue ◽  
Colorectal Cancer Surgery ◽  
Procedure Volume ◽  
Low Volume

Abstract Background The relationship between hospital surgical volume and outcome after colorectal cancer surgery has thoroughly been studied. However, few studies have assessed hospital surgical volume and failure-to-rescue (FTR) after colon and rectal cancer surgery. The aim of the current study is to evaluate FTR following colorectal cancer surgery between clinics based on procedure volume. Methods Patients undergoing colorectal cancer surgery in Sweden from January 2015 to January 2020 were recruited through the Swedish Colorectal Cancer Registry. The primary endpoint was FTR, defined as the proportion of patients with 30-day mortality after severe postoperative complications in colorectal cancer surgery. Severe postoperative complications were defined as Clavien–Dindo ≥ 3. FTR incidence rate ratios (IRR) were calculated comparing center volume stratified in low-volume (≤ 200 cases/year) and high-volume centers (> 200 cases/year), as well as with an alternative stratification comparing low-volume (< 50 cases/year), medium-volume (50–150 cases/year) and high-volume centers (> 150 cases/year). Results A total of 23,351 patients were included in this study, of whom 2964 suffered severe postoperative complication(s). Adjusted IRR showed no significant differences between high- and low-volume centers with an IRR of 0.97 (0.75–1.26, p = 0.844) in high-volume centers in the first stratification and an IRR of 2.06 (0.80–5.31, p = 0.134) for high-volume centers and 2.15 (0.83–5.56, p = 0.116) for medium-volume centers in the second stratification. Conclusion This nationwide retrospectively analyzed cohort study fails to demonstrate a significant association between hospital surgical volume and FTR after colorectal cancer surgery. Future studies should explore alternative characteristics and their correlation with FTR to identify possible interventions for the improvement of quality of care after colorectal cancer surgery.

P199 IS ROUTINE ICU ADMISSION NECESSARY AFTER TRANSTHORACIC ESOPHAGECTOMY FOR ESOPHAGEAL AND ESOPHAGOGASTRIC JUNCTION CANCER?

2019 ◽  
Vol 32 (Supplement_2) ◽  
Author(s):  
Andrea Pansa ◽  
Roit Anna Da ◽  
Silvia Basato ◽  
Damiano Gentile ◽  
Pietro Riva ◽  
...  
Keyword(s):  
Hospital Stay ◽  
Complication Rate ◽  
Esophagogastric Junction ◽  
Length Of Hospital Stay ◽  
High Volume ◽  
Type I ◽  
Transthoracic Esophagectomy ◽  
Short Term ◽  
Icu Admission ◽  
Esophagogastric Junction Cancer

Abstract Aim We evaluated short-term outcomes of esophagectomy for esophageal and esophagogastric carcinoma without routine postoperative admission to Intensive Care Unit (ICU). Background & Methods esophagectomy is subject to high rates of complications and mortality even when performed in high-volume centers and conventional postoperative management often involves routine ICU admission according to recent guidelines and recommendations1 . From January 2018 to June 2019 a total of 112 esophagectomies were performed in the Upper GI Surgery division of Humanitas Research Hospital. We included the 83 patients that underwent transthoracic esophagectomy with a hybrid technique (laparoscopy + right thoracotomy) and high intrathoracic anastomosis for esophageal and esophagogastric junction cancer. Preoperative assessment included a prehabilitation program (nutritional evaluation, respiratory physiotherapy and adjustment of cardiologic therapy). Postoperatively, patients were managed by surgical team members. We retrospectively recorded data on necessity of ICU, operative times, complication rate (according to ECCG)2,3, length of hospital stay, in-hospital, 30-day and 90-day mortality. Results 68 patients were males and 15 females. Mean age was 65 years old (range 29-82). 67 patients underwent neoadjuvant therapy (49 chemo-radiotherapy, 18 chemotherapy alone). Postoperative ICU admission was necessary in 6 patients (9,5%), reasons for admission were necessity of ventilatory weaning in 2 patients, high lactate levels in one patient, glottic oedema following oro-tracheal intubation in one patient, while in the other cases ICU admission was planned for severe comorbidities. Mean duration of prehabilitation was 20.3 days (1-107). Mean surgery duration was 452.4 minutes (337-549). Overall complication rate was 33.8%, with the most common complications being atrial fibrillation (50% of all complications) and urinary retention (20%). There were two type I anastomotic leaks. Median length of hospital stay was 11 days (range 8-29). All patients were alive at 30 and 90 days after surgery. Conclusion routine ICU admission is not necessary after transthoracic esophagectomy for cancer in over 90% of patients. Careful patients’ evaluation, stratification of the surgical risk and systematic use of a prehabilitation program, along with adequate peri-operative management, can narrow the need for postoperative ICU admission in the setting of a high-volume centre without any impact on short-term outcomes.

Unchanged safety outcomes in deep brain stimulation surgery for Parkinson disease despite a decentralization of care

2013 ◽  
Vol 119 (6) ◽  
pp. 1546-1555 ◽  
Author(s):  
Robert A. McGovern ◽  
John P. Sheehy ◽  
Brad E. Zacharia ◽  
Andrew K. Chan ◽  
Blair Ford ◽  
...  
Keyword(s):  
Deep Brain Stimulation ◽  
Parkinson Disease ◽  
Brain Stimulation ◽  
Length Of Hospital Stay ◽  
Critical Factor ◽  
High Volume ◽  
The United States ◽  
Primary Diagnosis ◽  
Low Volume ◽  
Deep Brain

Object Early work on deep brain stimulation (DBS) surgery, when procedures were mostly carried out in a small number of high-volume centers, demonstrated a relationship between surgical volume and procedural safety. However, over the past decade, DBS has become more widely available in the community rather than solely at academic medical centers. The authors examined the Nationwide Inpatient Sample (NIS) to study the safety of DBS surgery for Parkinson disease (PD) in association with this change in practice patterns. Methods The NIS is a stratified sample of 20% of all patient discharges from nonfederal hospitals in the United States. The authors identified patients with a primary diagnosis of PD (332.0) and a primary procedure code for implantation/replacement of intracranial neurostimulator leads (02.93) who underwent surgery between 2002 and 2009. They analyzed outcomes using univariate and hierarchical, logistic regression analyses. Results The total number of DBS cases remained stable from 2002 through 2009. Despite older and sicker patients undergoing DBS, procedural safety (rates of non-home discharges, complications) remained stable. Patients at low-volume hospitals were virtually indistinguishable from those at high-volume hospitals, except that patients at low-volume hospitals had slightly higher comorbidity scores (0.90 vs 0.75, p < 0.01). Complications, non-home discharges, length of hospital stay, and mortality rates did not significantly differ between low- and high-volume hospitals when accounting for hospital-related variables (caseload, teaching status, location). Conclusions Prior investigations have demonstrated a robust volume-outcome relationship for a variety of surgical procedures. However, the present study supports safety of DBS at smaller-volume centers. Prospective studies are required to determine whether low-volume centers and higher-volume centers have similar DBS efficacy, a critical factor in determining whether DBS is comparable between centers.

scholarly journals Variation in Annual Volume at a University Hospital Does Not Predict Mortality for Pancreatic Resections

HPB Surgery ◽  
2008 ◽  
Vol 2008 ◽  
pp. 1-6 ◽  
Author(s):  
Rita A. Mukhtar ◽  
Omar M. Kattan ◽  
Hobart W. Harris
Keyword(s):  
San Francisco ◽  
Postoperative Mortality ◽  
High Volume ◽  
Patient Characteristics ◽  
Mortality Rates ◽  
University Hospital ◽  
Complication Rates ◽  
Pancreatic Resections ◽  
Annual Volume ◽  
Low Volume

Annual volume of pancreatic resections has been shown to affect mortality rates, prompting recommendations to regionalize these procedures to high-volume hospitals. Implementation has been difficult, given the paucity of high-volume centers and the logistical hardships facing patients. Some studies have shown that low-volume hospitals achieve good outcomes as well, suggesting that other factors are involved. We sought to determine whether variations in annual volume affected patient outcomes in 511 patients who underwent pancreatic resections at the University of California, San Francisco between 1990 and 2005. We compared postoperative mortality and complication rates between low, medium, or high volume years, designated by the number of resections performed, adjusting for patient characteristics. Postoperative mortality rates did not differ between high volume years and medium/low volume years. As annual hospital volume of pancreatic resections may not predict outcome, identification of actual predictive factors may allow low-volume centers to achieve excellent outcomes.

Inequal benefits from regionalization of cancer care: The pancreatic cancer surgery paradigm.

2012 ◽  
Vol 30 (15_suppl) ◽  
pp. 4059-4059
Author(s):  
Theodore P. McDade ◽  
Jillian K Smith ◽  
Zeling Chau ◽  
Elan R. Witkowski ◽  
James K. West ◽  
...  
Keyword(s):  
Pancreatic Cancer ◽  
Cancer Care ◽  
High Volume ◽  
Cancer Surgery ◽  
Perioperative Outcomes ◽  
Hospital Inpatient ◽  
Median Income ◽  
Discharge Data ◽  
Pancreatic Resections ◽  
Low Volume

4059 Background: Regionalization has been proposed for high-level care, including multidisciplinary cancer treatment and complex procedures. Pancreatic resections can serve as a marker for both. Using Massachusetts Division of Health Care Finance and Policy (DHCFP) data, we investigated regionalization of surgery for pancreatic cancer (PCa), its potential effect on perioperative outcomes, and disparities in access to high-volume PCa surgery centers. Methods: Using MA DHCFP Hospital Inpatient Discharge Data, 2005-2009, 10,524 discharges for PCa were identified, of which 746 were associated with pancreatic resection. Discharges with missing or out-of-state residence were excluded (n=704). Using geodetic methods and ZIP codes, center-to-center distances were calculated between patient (pt) and treating hospital. Median ZIP income was estimated from 2009 census data. High volume hospitals (4 of 25 performing pancreatic resections in MA) were defined using Leapfrog Criteria (> 11 per year (87th percentile for MA). Chi-square and logistic regression analyses were performed using SAS software. Results: Median age was 65. Pts were predominantly White (87.2%), with median ZIP income of $54,677. Pts travelled in-state up to 112 miles (median 15.4), with the majority resected at high volume hospitals (76%). Median length of stay (LOS) was 8.0 days, with LOS>1 week associated with low volume hospitals (p=0.0002). Of 14 in-hospital deaths, 7 were at low volume hospitals (4.14% of 169 pts) compared to 7 at high volume hospitals (1.31% of 535 pts) (p=0.0214). Predictors of shorter travel distance were: Black race (OR 4.45 (95% CI 1.66-11.93)), operation at low volume hospital (OR 2.62 (95% CI 1.81-3.77), and increased age (per year) (OR 1.02 (95% CI 1.00-1.03), but not sex or median income. Conclusions: Using MA statewide discharge data, regionalization of pancreatic cancer surgery to high-volume, better-outcome centers is seen to be occurring. However, it is not uniform, and disparities exist between groups of cancer pts that do and do not travel for their care. In the current era of scrutiny on cost, quality, and access to cancer care, further study into predictors of pts receiving optimal care is warranted.

Nodal retrieval and short-term outcomes of robotic and laparoscopic colectomies for colon cancer.

2019 ◽  
Vol 37 (4_suppl) ◽  
pp. 713-713 ◽  
Author(s):  
Trang Nguyen ◽  
Stacey Stern ◽  
Ahmed Dehal ◽  
Brooke Vuong ◽  
Anton J. Bilchik
Keyword(s):  
Colon Cancer ◽  
High Volume ◽  
Oncologic Outcomes ◽  
Perioperative Outcomes ◽  
National Database ◽  
Community Hospitals ◽  
Short Term ◽  
Open Operation ◽  
Academic Hospitals ◽  
Low Volume

713 Background: It is debatable whether robotic colectomies is advantageous over laparoscopic colectomies for colon cancer (CC). We aim to evaluate oncologic and perioperative outcomes between robotic and laparoscopic colectomies in a national database. Methods: The National Cancer Database was queried from 2010-2014 for patients with resectable (stage I-III) CC. Lymph node (LN) retrieval, length of stay (LOS), perioperative outcomes and OS were analyzed based on type of surgery: right colectomy vs. left colectomy and robotic (ROBO) vs. laparoscopic (LAP). Results: 61,903 patients met inclusion criteria. There was no difference in inadequate LN retrieval (< 12 LN), or short-term mortality between ROBO and LAP groups. There was a significant decrease in conversion to an open operation and LOS for ROBO vs. LAP groups as well as increased 5 year OS (Table). ROBO colectomies increased four-fold over 5 years. About half were done at community hospitals (56%) and at low ROBO volume hospitals (47.2%). Inadequate LN retrieval in the ROBO group was greater at low volume centers (9.2%) compared to high volume centers (12.3%) (p < 0.0001) as well as at community hospitals (12.2%) compared to academic hospitals (8.5%) (p=0.0003). Conclusions: This population analysis showed that robotic colectomies was associated with equivalent short-term outcomes and LN retrieval as laparoscopic colectomies. However, half of robotic colectomies were done at community hospitals or low volume hospitals, where the rate of inadequate LN retrieval was higher than at academic hospitals or high volume centers. As robotic colectomies increases, it is important that technology is implemented judiciously so that oncologic outcomes are not compromised. [Table: see text]

Failure to Rescue As a Source of Variation in Hospital Mortality for Ovarian Cancer

2012 ◽  
Vol 30 (32) ◽  
pp. 3976-3982 ◽  
Author(s):  
Jason D. Wright ◽  
Thomas J. Herzog ◽  
Zainab Siddiq ◽  
Rebecca Arend ◽  
Alfred I. Neugut ◽  
...  
Keyword(s):  
Ovarian Cancer ◽  
Complication Rate ◽  
Major Complication ◽  
High Volume ◽  
Complication Rates ◽  
Failure To Rescue ◽  
High Volume Hospital ◽  
Lower Complication ◽  
Major Complication Rate ◽  
Low Volume

Purpose Although the association between high surgical volume and improved outcomes from procedures is well described, the mechanisms that underlie this association are uncertain. There is growing recognition that high-volume hospitals may not necessarily have lower complication rates but rather may be better at rescuing patients with complications. We examined the role of complications, failure to rescue from complications, and mortality based on hospital volume for ovarian cancer. Patients and Methods The Nationwide Inpatient Sample was used to identify women who underwent surgery for ovarian cancer from 1988 to 2009. Hospitals were ranked on the basis of their procedure volume. We determined the risk-adjusted mortality, major complication rate, and “failure to rescue” rate (mortality in patients with a major complication) for each tertile. Univariate and multivariate associations were then compared. Results We identified 36,624 patients. The mortality rate for the cohort was 1.6%. The major complication rate was 20.4% at low-volume, 23.4% at intermediate-volume, and 24.6% at high-volume hospitals (P < .001). However, the rate of failure to rescue (death after a complication) was markedly higher at low-volume (8.0%) compared with high-volume hospitals (4.9%; P < .001). After accounting for patient and hospital characteristics, women treated at low-volume hospitals who experienced a complication were 48% more likely (odds ratio [OR], 1.48; 95% CI, 1.11 to 1.99) to die than patients with a complication at a high-volume hospital. Conclusion Mortality is lower for patients with ovarian cancer treated at high-volume hospitals. The reduction in mortality does not appear to be the result of lower complications rates but rather a result of the ability of high-volume hospitals to rescue patients with complications.

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