Department of Surgery, University of California, San Francisco, San Francisco, CA, USA.
School of Medicine, University of California, San Francisco, San Francisco, CA, USA.
Ann Surg Oncol. 2022 Mar;29(3):1566-1574. doi: 10.1245/s10434-021-10984-1. Epub 2021 Nov 1.
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.
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.
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).
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.
指南建议将微创胰十二指肠切除术（MIPD）限制在高容量中心进行。然而，高容量护理的定义仍不清楚。我们旨在客观地定义每家医院每年进行的 MIPD 的最低数量，以改善当代患者队列的结果。
从国家癌症数据库（2010-2017 年）中纳入接受 MIPD 的可切除胰腺腺癌患者。使用受限立方样条进行多变量建模，以确定与较低的 90 天死亡率相关的 MIPD 年度医院量阈值。将在低容量（≤模型确定的截止值）和高容量（>截止值）中心治疗的患者的结果进行比较。
在 3079 名患者中，有 141 名（5%）在 90 天内死亡。医院的中位数容量为 6（范围 1-73）例/年。调整后，医院容量的增加与 90 天死亡率的降低相关，最高可达 19 例（95%CI 16-25），表明阈值为 20 例/年。大多数病例（82%）在低容量（<20 例/年）中心完成。调整后，低容量中心的 MIPD 与 90 天死亡率增加相关（OR 2.7；p = 0.002）。住院时间、阳性手术边缘、30 天再入院和总生存情况相似。对最近两年（n = 1031）的分析显示，低容量中心的患者（78.2%）年龄较小，肿瘤进展程度较低，但住院时间较长（8 天对 7 天；p<0.001），90 天死亡率增加（7%对 2%；p = 0.009）。
切分点分析确定了一个至少 20 例 MIPD 例/年的阈值，与术后死亡率降低相关。该阈值应告知旨在促进这种复杂手术安全实施的国家指南和机构层面的协议。
