What constitutes a "High-Volume" hospital for pancreatic resection?
ABSTRACT Annual institution resection volume has been proposed for defining centers of excellence, with various cut-offs for defining "high-volume" centers used. This study aimed to define an objective, evidence-based operative volume threshold associated with improved postoperative outcomes after pancreatic resection.
This retrospective analysis of patients who underwent pancreatic resection in the Nationwide Inpatient Sample, a 20% representative sample of patients in the US between 1998 and 2003, was performed using multivariable logistic regression. Different models of annual hospital resection volume were analyzed and the goodness of fit of each "high-volume" model to postoperative mortality was compared through use of the pseudo r(2).
Based on analysis of 7,558 patients who underwent pancreatic resection, median annual institution resection volume was 15 (range 1 to 254), and overall in-hospital mortality was 7.6%. The best model of "high-volume" centers was an annual institution resection volume of 19 or more, as determined by goodness of fit (r(2) of 5.29%). But there was little difference in data variance explained between this best model and other "high-volume" models. The model without any volume variable had a goodness-of-fit r(2) of 3.57%, suggesting that volume explains less than 2% of data variance in perioperative death after pancreatic resection.
Very little difference was observed in the explanatory powers of models of "high-volume" centers. Although volume has an important impact on mortality, volume cut-off is necessary but insufficient for defining centers of excellence. Volume appears to function as an imperfect surrogate for other variables, which may better define centers of excellence.
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ABSTRACT: Endoscopic treatment for pancreatobiliary diseases is less invasive than surgery and percutaneous transhepatic biliary drainage is highly beneficial to patients. The endoscopic approach is indicated for an increasing number of patients, including those who have undergone previous gastrointestinal surgery, although these patients face two major challenges. First, the endoscopic approach to the afferent loop, blind end, and the site of choledochojejunostomy is difficult with the use of a conventional endoscope because of the distance from the gastrojejunal anastomosis site, unusual anatomical features of the intestine such as its winding shape, and postoperative adhesion. Second, it is difficult to reach Vater's papilla or the site of choledochojejunostomy andto cannulate selectively into the pancreatic and/or biliary duct. The balloon-assisted endoscope (BAE), a recently developed technology, can be useful for carrying out endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy. ERCP using the BAE is highly effective and safe in patients with altered gastrointestinal anatomy, especially in patients with Roux-en-Y reconstruction.Digestive Endoscopy 09/2013; DOI:10.1111/den.12175 · 1.99 Impact Factor
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ABSTRACT: Background: The volume effect in pancreatic surgery is well established. Regionalization to high-volume centres has been proposed. The effect of this proposal on practice patterns is unknown. Methods: Retrospective review of pancreatectomy patients in the Nationwide Inpatient Sample 2004-2011. Inpatient mortality and complication rates were calculated. Patients were stratified by annual centre pancreatic resection volume (low <5, medium 5-18, high >18). Multivariable regression model evaluated predictors of resection at a high-volume centre. Results: In total, 129 609 patients underwent a pancreatectomy. The crude inpatient mortality rate was 4.3%. 36.0% experienced complications. 66.5% underwent a resection at high-volume centres. In 2004, low-, medium-and high-volume centres resected 16.3%, 24.5% and 59.2% of patients, compared with 7.6%, 19.3% and 73.1% in 2011. High-volume centres had lower mortality (P < 0.001), fewer complications (P < 0.001) and a shorter median length of stay (P < 0.001). Patients at non-high-volume centres had more comorbidities (P = 0.001), lower rates of private insurance (P < 0.001) and more non-elective admissions (P < 0.001). Discussion: In spite of a shift to high-volume hospitals, a substantial cohort still receives a resection outside of these centres. Patients receiving non-high-volume care demonstrate less favourable comorbidities, insurance and urgency of operation. The implications are twofold: already disadvantaged patients may not benefit from the high-volume effect; and patients predisposed to do well may contribute to observed superior outcomes at high-volume centres.HPB 06/2014; 16(10). DOI:10.1111/hpb.12283 · 2.05 Impact Factor