Erschienen in:
01.11.2021 | Pancreatic Tumors
Determining Hospital Volume Threshold for Safety of Minimally Invasive Pancreaticoduodenectomy: A Contemporary Cutpoint Analysis
verfasst von:
Patricia C. Conroy, MD, Lucia Calthorpe, BA, MPhil, Joseph A. Lin, MD, MPH, Sarah Mohamedaly, MD, MPH, Alex Kim, MD, PhD, Kenzo Hirose, MD, Eric Nakakura, MD, PhD, Carlos Corvera, MD, Julie Ann Sosa, MD, MA, Ankit Sarin, MD, Kimberly S. Kirkwood, MD, Adnan Alseidi, MD, EdM, Mohamed A. Adam, MD
Erschienen in:
Annals of Surgical Oncology
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Ausgabe 3/2022
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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.