Is Centralization Needed for Patients Undergoing Distal Pancreatectomy?

Abstract

Objective The centralization of complex surgical procedures is associated with better postoperative outcomes. However, little is known about the impact of hospital volume on the outcome after distal pancreatectomy. Methods Using the French national hospital discharge database, we identified all patients having undergone distal pancreatectomy in France between 2012 and 2015. A spline model was applied to determine the caseload cut-off in annual distal pancreatectomy that influenced 90-day postoperative mortality. Results A total of 3314 patients were identified. Use of a spline model did not reveal a cut-off in the annual distal pancreatectomy caseload. By taking the median number of distal pancreatectomy (n = 5) and the third quartile (n = 15), we stratified centers into low, intermediate, and high hospital volume groups. The overall postoperative mortality rate was 3.0% and did not differ significantly between these groups. In a multivariable analysis, age, Charlson comorbidity score, septic complications, hemorrhage, shock, and reoperation were independently associated with a greater overall risk of death. However, hospital volume had no impact on mortality after distal pancreatectomy (odds ratio, 0.954; 95% confidence interval, 0.552–1.651, P = 0.867). Conclusions Hospital volume does not seem to influence mortality after distal pancreatectomy in France, and centralization may not necessarily improve outcomes.

Defining Benchmark Outcomes for Distal Pancreatectomy

“…[7][8][9] However, the findings of recent nationwide studies indicate that centralization for DP may be unnecessary as there was no evidence to indicate that hospital volume affected DP outcome. 3 Nevertheless, establishing standardized key metrics in patients who undergo DP seems to be crucial. Among these metrics, mortality alone is no longer sufficient to define surgical standards and other key parameters, such as intraoperative and oncological data, are usually ignored.…”

“…DP is considered a less complex procedure with lower morbidity and mortality rates than reported after pancreaticoduodenectomy (PD) 1,2. However, data from nationwide studies suggest that postoperative mortality after DP may occur in up to 3% of the cases 3. Recently, minimally invasive distal pancreatectomy (MIDP) have been reported as improving postoperative outcomes as compared to open PD without any difference regarding oncological outcomes 4–6…”

“…Therefore, some authors suggest that centralization of pancreatic surgery should be mandatory to improve outcomes 7–9. However, the findings of recent nationwide studies indicate that centralization for DP may be unnecessary as there was no evidence to indicate that hospital volume affected DP outcome 3…”

“…1,2 However, data from nationwide studies suggest that postoperative mortality after DP may occur in up to 3% of the cases. 3 Recently, minimally invasive distal pancreatectomy (MIDP) have been reported as improving postoperative outcomes as compared to open PD without any difference regarding oncological outcomes. [4][5][6] Despite these findings, DP remains a highly complex procedure.…”

Comment on: Failure to rescue in patients with distal pancreatectomy: a nationwide analysis of 10,632 patients

“…In the meantime, Roussel et al recently published a series of DP based on the same national French database (2). The aim of this series was to define high volume centers and identify a volume cut off before evaluating its impact on postoperative course.…”