Patricia C Conroy1, Lucia Calthorpe2, Joseph A Lin1, Sarah Mohamedaly1, Alex Kim3, Kenzo Hirose4, Eric Nakakura4, Carlos Corvera4, Julie Ann Sosa4, Ankit Sarin4, Kimberly S Kirkwood4, Adnan Alseidi4, Mohamed A Adam5. 1. Department of Surgery, University of California, San Francisco, San Francisco, CA, USA. 2. School of Medicine, University of California, San Francisco, San Francisco, CA, USA. 3. Department of Surgery, Division of Surgical Oncology, The Ohio State University, Columbus, OH, USA. 4. Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, San Francisco, CA, USA. 5. Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, San Francisco, CA, USA. mohamed.adam@ucsf.edu.
Abstract
BACKGROUND: Guidelines recommend limiting minimally invasive pancreaticoduodenectomy (MIPD) to high-volume centers. However, the definition of high-volume care remains unclear. We aimed to objectively define a minimum number of MIPD performed annually per hospital associated with improved outcomes in a contemporary patient cohort. PATIENTS AND METHODS: Resectable pancreatic adenocarcinoma patients undergoing MIPD were included from the National Cancer Database (2010-2017). Multivariable modeling with restricted cubic splines was employed to identify an MIPD annual hospital volume threshold associated with lower 90-day mortality. Outcomes were compared between patients treated at low-volume (≤ model-identified cutoff) and high-volume (> cutoff) centers. RESULTS: Among 3079 patients, 141 (5%) died within 90 days. Median hospital volume was 6 (range 1-73) cases/year. After adjustment, increasing hospital volume was associated with decreasing 90-day mortality for up to 19 (95% CI 16-25) cases/year, indicating a threshold of 20 cases/year. Most cases (82%) were done at low-volume (< 20 cases/year) centers. With adjustment, MIPD at low-volume centers was associated with increased 90-day mortality (OR 2.7; p = 0.002). Length of stay, positive surgical margins, 30-day readmission, and overall survival were similar. On analysis of the most recent two years (n = 1031), patients at low-volume centers (78.2%) were younger and had less advanced tumors but had longer length of stay (8 versus 7 days; p < 0.001) and increased 90-day mortality (7% versus 2%; p = 0.009). CONCLUSIONS: The cutpoint analysis identified a threshold of at least 20 MIPD cases/year associated with lower postoperative mortality. This threshold should inform national guidelines and institution-level protocols aimed at facilitating the safe implementation of this complex procedure.
BACKGROUND: Guidelines recommend limiting minimally invasive pancreaticoduodenectomy (MIPD) to high-volume centers. However, the definition of high-volume care remains unclear. We aimed to objectively define a minimum number of MIPD performed annually per hospital associated with improved outcomes in a contemporary patient cohort. PATIENTS AND METHODS: Resectable pancreatic adenocarcinoma patients undergoing MIPD were included from the National Cancer Database (2010-2017). Multivariable modeling with restricted cubic splines was employed to identify an MIPD annual hospital volume threshold associated with lower 90-day mortality. Outcomes were compared between patients treated at low-volume (≤ model-identified cutoff) and high-volume (> cutoff) centers. RESULTS: Among 3079 patients, 141 (5%) died within 90 days. Median hospital volume was 6 (range 1-73) cases/year. After adjustment, increasing hospital volume was associated with decreasing 90-day mortality for up to 19 (95% CI 16-25) cases/year, indicating a threshold of 20 cases/year. Most cases (82%) were done at low-volume (< 20 cases/year) centers. With adjustment, MIPD at low-volume centers was associated with increased 90-day mortality (OR 2.7; p = 0.002). Length of stay, positive surgical margins, 30-day readmission, and overall survival were similar. On analysis of the most recent two years (n = 1031), patients at low-volume centers (78.2%) were younger and had less advanced tumors but had longer length of stay (8 versus 7 days; p < 0.001) and increased 90-day mortality (7% versus 2%; p = 0.009). CONCLUSIONS: The cutpoint analysis identified a threshold of at least 20 MIPD cases/year associated with lower postoperative mortality. This threshold should inform national guidelines and institution-level protocols aimed at facilitating the safe implementation of this complex procedure.
Authors: Ignasi Poves; Fernando Burdío; Olga Morató; Mar Iglesias; Aleksander Radosevic; Lucas Ilzarbe; Laura Visa; Luís Grande Journal: Ann Surg Date: 2018-11 Impact factor: 12.969
Authors: Paul J Speicher; Daniel P Nussbaum; Rebekah R White; Sabino Zani; Paul J Mosca; Dan G Blazer; Bryan M Clary; Theodore N Pappas; Douglas S Tyler; Alexander Perez Journal: Ann Surg Oncol Date: 2014-06-13 Impact factor: 5.344
Authors: Thomas W Wood; Sharona B Ross; Ty A Bowman; Amanda Smart; Carrie E Ryan; Benjamin Sadowitz; Darrell Downs; Alexander S Rosemurgy Journal: Am Surg Date: 2016-05 Impact factor: 0.688
Authors: Mohamed Abdelgadir Adam; John Pura; Paolo Goffredo; Michaela A Dinan; Shelby D Reed; Randall P Scheri; Terry Hyslop; Sanziana A Roman; Julie A Sosa Journal: J Clin Oncol Date: 2015-06-15 Impact factor: 44.544
Authors: Mohamed Abdelgadir Adam; Samantha Thomas; Linda Youngwirth; Terry Hyslop; Shelby D Reed; Randall P Scheri; Sanziana A Roman; Julie A Sosa Journal: Ann Surg Date: 2017-02 Impact factor: 12.969
Authors: Mohamed Abdelgadir Adam; Kingshuk Choudhury; Michaela A Dinan; Shelby D Reed; Randall P Scheri; Dan G Blazer; Sanziana A Roman; Julie A Sosa Journal: Ann Surg Date: 2015-08 Impact factor: 12.969
Authors: Krista Hachey; Ryan Morgan; Amy Rosen; Sowmya R Rao; David McAneny; Jennifer Tseng; Gerard Doherty; Teviah Sachs Journal: Ann Surg Oncol Date: 2018-09-05 Impact factor: 5.344
Authors: Tsafrir Vanounou; Jennifer L Steel; Kevin Tri Nguyen; Allan Tsung; J Wallis Marsh; David A Geller; T Clark Gamblin Journal: Ann Surg Oncol Date: 2009-12-22 Impact factor: 5.344
Authors: Antonio Giuliani; Pasquale Avella; Anna Lucia Segreto; Maria Lucia Izzo; Antonio Buondonno; Mariagrazia Coluzzi; Micaela Cappuccio; Maria Chiara Brunese; Roberto Vaschetti; Andrea Scacchi; Germano Guerra; Bruno Amato; Fulvio Calise; Aldo Rocca Journal: Front Surg Date: 2021-12-21