Revista de Oncología Integrativa

Pancreatico-Duodenectomy with High Quality Results in a Medium Volume Centre. What are the Australian Definitions of Low Volume?

Abstract

Ephraem Colin Lye, Donna Gillies and Jon Gani

Introduction: Controversy about Pancreatico-Duodenectomy (PD) has persisted since it was first performed by Kausch a century ago and later popularised by Whipple. Evidence that a certain critical caseload volume is required to undertake this kind of surgery with low mortality has been the subject of some debate. Definitions of high and low volume centres and surgeons have been proposed but they differ greatly between health systems and countries.
The objective of this analysis was to determine whether it is possible to deliver pancreatico-duodenectomy at global standards in a regional city and to see if we can help define the minimum acceptable number of procedures annually compatible with providing such a service.
Methods: A ten-year retrospective study from the period of October 2002 to October 2012 was undertaken in the 1 public and 2 private hospital in Newcastle Australia where all the PDs for a regional population of 840000 were performed.
Results: 123 pancreatico-duodenectomies were performed in this period. The mean number of operations performed each year including all hospitals combined was 12.3. This is equivalent to a medium volume centre by European definitions. The number of operations per surgeon per annum ranged from 0.2 per year to 5.8. 83.7% of patients suffered no significant complications; 30-day mortality was 4.1%. Significant differences were found between surgeons total significant complication rates, which ranged from 8.6% to 50%. 30-day mortality ranged from 0% to 50%. 3 surgeons performed >3 operations per year. These were all designated medium volume surgeons and they performed 91% of all PDs in this series (112/123). The 3 other surgeons performed 9% (11/123) and were designated very low volume surgeons. One hospital performed only 4 PDs during the study period and was designated a very low volume hospital (<1case per annum). When the data from medium volume surgeons and
medium volume hospitals was compared with the data from very low volume surgeons and hospitals there was a statistically significant difference in overall complication rates and mortality. Exclusion of the very low volume surgeons and the very low volume institution was associated with 1.9% 30-day mortality, a 12% significant morbidity and a 31% actuarial 5-year survival for periampullary malignancy.
Conclusion: There are both surgeon and hospital volume effects on outcome after PD. We have demonstrated that specialised Upper GI/HPB surgeons can achieve pancreatico-duodenectomy results in a medium volume centre equivalent to those achieved high volume centres.