Duke University Medical Center, Department of Surgery, Durham, NC.
Ann Surg. 2017 Aug;266(2):333-338. doi: 10.1097/SLA.0000000000001924.
This study compares outcomes following pancreaticoduodenectomy (PD) for patients treated at local, low-volume centers and those traveling to high-volume centers.
Although outcomes for PD are superior at high-volume institutions, not all patients live in proximity to major medical centers. Theoretical advantages for undergoing surgery locally exist.
The 1998 to 2012 National Cancer Data Base was queried for T1-3N0-1M0 pancreatic adenocarcinoma patients who underwent PD. Travel distances to treatment centers were calculated. Overlaying the upper and lower quartiles of travel distance with institutional volume established short travel/low-volume (ST/LV) and long travel/high-volume (LT/HV) cohorts. Overall survival was evaluated.
Of 7086 patients, 773 ST/LV patients traveled ≤6.3 (median 3.2) miles to centers performing ≤3.3 PDs yearly, and 758 LT/HV patients traveled ≥45 (median 97.3) miles to centers performing ≥16 PDs yearly. LT/HV patients had higher stage disease (P < 0.001), but lower margin positivity (20.5% vs 25.9%, P = 0.01) and improved lymphadenectomy (16 vs 11 nodes, P < 0.01). Moreover, LT/HV patients had shorter hospitalizations (9 vs 12 days, P < 0.01) and lower 30-day mortality (2.0% vs 6.3%, P < 0.01) with similar 30-day readmission rates (10.1% vs 9.8%, P = 0.83). Despite more advanced disease, LT/HV patients had superior unadjusted survival (20.3 vs 15.7 months). After adjustment, travel to a high-volume center remained associated with reduced long-term mortality (hazard ratio 0.75, P < 0.01).
Despite an increased travel burden, patients treated at high-volume centers had improved perioperative outcomes, short-term mortality, and overall survival. These data support ongoing efforts to centralize care for patients undergoing PD.
本研究比较了在当地低容量中心和前往高容量中心接受治疗的患者行胰十二指肠切除术（PD）后的结果。
尽管在高容量机构进行 PD 的结果更好，但并非所有患者都居住在主要医疗中心附近。在当地进行手术存在理论上的优势。
通过查询 1998 年至 2012 年国家癌症数据库中接受 PD 的 T1-3N0-1M0 胰腺腺癌患者的数据，计算患者前往治疗中心的距离。通过将旅行距离的上四分位数和下四分位数与机构容量进行叠加，确定短距离/低容量（ST/LV）和长距离/高容量（LT/HV）队列。评估总生存率。
在 7086 例患者中，773 例 ST/LV 患者前往每年施行≤3.3 例 PD 的中心的距离≤6.3（中位数 3.2）英里，758 例 LT/HV 患者前往每年施行≥16 例 PD 的中心的距离≥45（中位数 97.3）英里。LT/HV 患者的疾病分期更高（P<0.001），但切缘阳性率较低（20.5%比 25.9%，P=0.01），淋巴结清扫更充分（16 个比 11 个，P<0.01）。此外，LT/HV 患者的住院时间更短（9 天比 12 天，P<0.01），30 天死亡率更低（2.0%比 6.3%，P<0.01），30 天再入院率相似（10.1%比 9.8%，P=0.83）。尽管疾病更晚期，LT/HV 患者的无调整生存率仍更高（20.3 比 15.7 个月）。校正后，前往高容量中心仍然与降低长期死亡率相关（风险比 0.75，P<0.01）。
尽管旅行负担增加，但在高容量中心接受治疗的患者具有更好的围手术期结局、短期死亡率和总体生存率。这些数据支持为接受 PD 的患者集中治疗的持续努力。
