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Determining Hospital Volume Threshold for Safety of Minimally Invasive Pancreaticoduodenectomy: A Contemporary Cutpoint Analysis

  • Pancreatic Tumors
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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.

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Data Access, Responsibility, and Analysis

Statistical analysis was performed by Dr. Mohamed Adam. Dr. Adam had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

References

  1. Ohtani H, Tamamori Y, Noguchi K, et al. A meta-analysis of randomized controlled trials that compared laparoscopy-assisted and open distal gastrectomy for early gastric cancer. J Gastrointest Surg. 2010;14(6):958–64. https://doi.org/10.1007/s11605-010-1195-x.

    Article  PubMed  Google Scholar 

  2. Vanounou T, Steel JL, Nguyen KT, et al. Comparing the clinical and economic impact of laparoscopic versus open liver resection. Ann Surg Oncol. 2010;17(4):998–1009. https://doi.org/10.1245/s10434-009-0839-0.

    Article  PubMed  Google Scholar 

  3. Anderson KL, Adam MA, Thomas S, Roman SA, Sosa JA. Impact of minimally invasive vs. open distal pancreatectomy on use of adjuvant chemoradiation for pancreatic adenocarcinoma. Am J Surg. 2017;213(4):601–5. https://doi.org/10.1016/j.amjsurg.2017.01.005.

    Article  PubMed  Google Scholar 

  4. Varley PR, Zenati MS, Klobuka A, et al. Does robotic pancreaticoduodenectomy improve outcomes in patients with high risk morphometric features compared to the open approach. HPB (Oxford). 2019;21(6):695–701. https://doi.org/10.1016/j.hpb.2018.10.016.

    Article  Google Scholar 

  5. Baimas-George M, Watson M, Murphy KJ, et al. Robotic pancreaticoduodenectomy may offer improved oncologic outcomes over open surgery: a propensity-matched single-institution study. Surg Endosc. 2020;34(8):3644–9. https://doi.org/10.1007/s00464-020-07564-x.

    Article  PubMed  Google Scholar 

  6. Palanivelu C, Senthilnathan P, Sabnis SC, et al. Randomized clinical trial of laparoscopic versus open pancreatoduodenectomy for periampullary tumours. Br J Surg. 2017;104(11):1443–50. https://doi.org/10.1002/bjs.10662.

    Article  CAS  PubMed  Google Scholar 

  7. Poves I, Burdío F, Morató O, et al. Comparison of perioperative outcomes between laparoscopic and open approach for pancreatoduodenectomy: the PADULAP randomized controlled trial. Ann Surg. 2018;268(5):731–9. https://doi.org/10.1097/SLA.0000000000002893.

    Article  PubMed  Google Scholar 

  8. Adam MA, Choudhury K, Dinan MA, et al. Minimally invasive versus open pancreaticoduodenectomy for cancer: practice patterns and short-term outcomes among 7061 patients. Ann Surg. 2015;262(2):372–7. https://doi.org/10.1097/SLA.0000000000001055.

    Article  PubMed  Google Scholar 

  9. Sharpe SM, Talamonti MS, Wang CE, et al. Early national experience with laparoscopic pancreaticoduodenectomy for ductal adenocarcinoma: a comparison of laparoscopic pancreaticoduodenectomy and open pancreaticoduodenectomy from the National Cancer Data Base. J Am Coll Surg. 2015;221(1):175–84. https://doi.org/10.1016/j.jamcollsurg.2015.04.021.

    Article  PubMed  Google Scholar 

  10. van Hilst J, de Rooij T, Bosscha K, et al. Laparoscopic versus open pancreatoduodenectomy for pancreatic or periampullary tumours (LEOPARD-2): a multicentre, patient-blinded, randomised controlled phase 2/3 trial. Lancet Gastroenterol Hepatol. 2019;4(3):199–207. https://doi.org/10.1016/S2468-1253(19)30004-4.

    Article  PubMed  Google Scholar 

  11. Adam MA, Thomas S, Youngwirth L, Pappas T, Roman SA, Sosa JA. Defining a hospital volume threshold for minimally invasive pancreaticoduodenectomy in the United States. JAMA Surg. 2017;152(4):336–42. https://doi.org/10.1001/jamasurg.2016.4753.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Ahola R, Siiki A, Vasama K, Vornanen M, Sand J, Laukkarinen J. Effect of centralization on long-term survival after resection of pancreatic ductal adenocarcinoma. Br J Surg. 2017;104(11):1532–8. https://doi.org/10.1002/bjs.10560.

    Article  CAS  PubMed  Google Scholar 

  13. Asbun HJ, Moekotte AL, Vissers FL, et al. The Miami international evidence-based guidelines on minimally invasive pancreas resection. Ann Surg. 2020;271(1):1–14. https://doi.org/10.1097/SLA.0000000000003590.

    Article  PubMed  Google Scholar 

  14. Network NCC. Clinical practice guidelines in oncology: pancreatic adenocarcinoma (Version 1.2021). https://www.nccn.org/professionals/physician_gls/pdf/pancreatic.pdf. Accessed 10 Feb 2021.

  15. Speicher PJ, Nussbaum DP, White RR, et al. Defining the learning curve for team-based laparoscopic pancreaticoduodenectomy. Ann Surg Oncol. 2014;21(12):4014–9. https://doi.org/10.1245/s10434-014-3839-7.

    Article  PubMed  Google Scholar 

  16. Torphy RJ, Friedman C, Halpern A, et al. Comparing short-term and oncologic outcomes of minimally invasive versus open pancreaticoduodenectomy across low and high volume centers. Ann Surg. 2019;270(6):1147–55. https://doi.org/10.1097/SLA.0000000000002810.

    Article  PubMed  Google Scholar 

  17. About the National Cancer Database. https://www.facs.org/Quality-Programs/Cancer/NCDB/about. Accessed 22 Dec 2020.

  18. Adam MA, Pura J, Goffredo P, et al. Presence and number of lymph node metastases are associated with compromised survival for patients younger than age 45 years with papillary thyroid cancer. J Clin Oncol. 2015;33(21):2370–5. https://doi.org/10.1200/JCO.2014.59.8391.

    Article  PubMed  Google Scholar 

  19. Croome KP, Farnell MB, Que FG, et al. Total laparoscopic pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: oncologic advantages over open approaches? Ann Surg. 2014;260(4):633–8. https://doi.org/10.1097/SLA.0000000000000937 (discussion 638–640).

    Article  PubMed  Google Scholar 

  20. Wang M, Li D, Chen R, et al. Laparoscopic versus open pancreatoduodenectomy for pancreatic or periampullary tumours: a multicentre, open-label, randomised controlled trial. Lancet Gastroenterol Hepatol. 2021. https://doi.org/10.1016/S2468-1253(21)00054-6.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Wang M, Peng B, Liu J, et al. Practice patterns and perioperative outcomes of laparoscopic pancreaticoduodenectomy in China: a retrospective multicenter analysis of 1029 patients. Ann Surg. 2021;273(1):145–53. https://doi.org/10.1097/SLA.0000000000003190.

    Article  PubMed  Google Scholar 

  22. Adam MA, Thomas S, Youngwirth L, et al. Is there a minimum number of thyroidectomies a surgeon should perform to optimize patient outcomes? Ann Surg. 2017;265(2):402–7. https://doi.org/10.1097/SLA.0000000000001688.

    Article  PubMed  Google Scholar 

  23. Hachey K, Morgan R, Rosen A, et al. Quality comes with the (anatomic) territory: evaluating the impact of surgeon operative mix on patient outcomes after pancreaticoduodenectomy. Ann Surg Oncol. 2018;25(13):3795–803. https://doi.org/10.1245/s10434-018-6732-y.

    Article  PubMed  Google Scholar 

  24. Liao CH, Wu YT, Liu YY, et al. Systemic review of the feasibility and advantage of minimally invasive pancreaticoduodenectomy. World J Surg. 2016;40(5):1218–25. https://doi.org/10.1007/s00268-016-3433-1.

    Article  PubMed  Google Scholar 

  25. Wood TW, Ross SB, Bowman TA, et al. High-volume hospitals with high-volume and low-volume surgeons: is there a “field effect” for pancreaticoduodenectomy? Am Surg. 2016;82(5):407–11.

    Article  Google Scholar 

  26. Joseph B, Morton JM, Hernandez-Boussard T, Rubinfeld I, Faraj C, Velanovich V. Relationship between hospital volume, system clinical resources, and mortality in pancreatic resection. J Am Coll Surg. 2009;208(4):520–7. https://doi.org/10.1016/j.jamcollsurg.2009.01.019.

    Article  PubMed  Google Scholar 

  27. Moekotte AL, Rawashdeh A, Asbun HJ, et al. Safe implementation of minimally invasive pancreas resection: a systematic review. HPB (Oxford). 2020;22(5):637–48. https://doi.org/10.1016/j.hpb.2019.11.005.

    Article  Google Scholar 

  28. Hogg ME, Besselink MG, Clavien PA, et al. Training in minimally invasive pancreatic resections: a paradigm shift away from “see one, do one, teach one.” HPB (Oxford). 2017;19(3):234–45. https://doi.org/10.1016/j.hpb.2017.01.016.

    Article  Google Scholar 

  29. Tsamalaidze L, Stauffer JA. Pancreaticoduodenectomy: minimizing the learning curve. J Vis Surg. 2018;4:64. https://doi.org/10.21037/jovs.2018.03.07.

    Article  PubMed  PubMed Central  Google Scholar 

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Funding

P.C.C. was supported by the National Center for Advancing Translational Sciences, National Institutes of Health, UCSF-CTSI Grant Number TL1 TR001871. J.A.L. was supported by the National Cancer Institute, National Institutes of Health, Grant Number T32CA25107001, and S.M. was supported by the National Institutes of Health, Grant Number 5T32AI125222-05. These contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH.

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Authors and Affiliations

  1. Department of Surgery, University of California, San Francisco, San Francisco, CA, USA

    Patricia C. Conroy MD, Joseph A. Lin MD, MPH & Sarah Mohamedaly MD, MPH

  2. School of Medicine, University of California, San Francisco, San Francisco, CA, USA

    Lucia Calthorpe BA, MPhil

  3. Department of Surgery, Division of Surgical Oncology, The Ohio State University, Columbus, OH, USA

    Alex Kim MD, PhD

  4. Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, San Francisco, CA, USA

    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

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  1. Patricia C. Conroy MD
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Contributions

PCC, MD: Conceptualization, data curation, writing—original draft, writing—review and editing, visualization, project administration. LC, BA, MPhil: Writing—original draft, writing—review and editing. JAL, MD, MPH: Writing—review and editing. SM, MD, MPH: Writing—review and editing. AK, MD, PhD: Conceptualization, writing—review and editing. KH, MD: Conceptualization, writing—review and editing. EN, MD, PhD: Conceptualization, writing—review and editing. CC, MD: Conceptualization, writing—review and editing. JAS, MD, MA: Writing—review and editing. AS, MD: Writing—review and editing. KSK, MD: Conceptualization, writing—review and editing. AA, MD, EdM: Conceptualization, writing—review and editing. MAA, MD: Conceptualization, methodology, software, validation, formal analysis, investigation, resources, writing—review and editing, supervision, project administration.

Corresponding author

Correspondence to Mohamed A. Adam MD.

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Disclosures

J.A.S. is a member of the Data Monitoring Committee of the Medullary Thyroid Cancer Consortium Registry supported by GlaxoSmithKline, Novo Nordisk, Astra Zeneca, and Eli Lilly. She receives institutional research funding from Exelixis and Eli Lilly. All other authors declare no conflicts of interest. All other authors declare no conflicts of interest.

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Conroy, P.C., Calthorpe, L., Lin, J.A. et al. Determining Hospital Volume Threshold for Safety of Minimally Invasive Pancreaticoduodenectomy: A Contemporary Cutpoint Analysis. Ann Surg Oncol 29, 1566–1574 (2022). https://doi.org/10.1245/s10434-021-10984-1

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