Variation in pancreatoduodenectomy as delivered in two national audits

Abstract

Background: Nationwide audits facilitate quality and outcome assessment of pancreatoduodenectomy. Differences may exist between countries but studies comparing nationwide outcomes of pancreatoduodenectomy based on audits are lacking. This study aimed to compare the German and Dutch audits for external data validation.Methods: Anonymized data from patients undergoing pancreatoduodenectomy between 2014 and 2016 were extracted from the German Society for General and Visceral Surgery StuDoQ|Pancreas and Dutch Pancreatic Cancer Audit, and compared using descriptive statistics. Univariable and multivariable risk analyses were undertaken.Results: Overall, 4495 patients were included, 2489 in Germany and 2006 in the Netherlands. Adenocarcinoma was a more frequent indication for pancreatoduodenectomy in the Netherlands. German patients had worse ASA fitness grades, but Dutch patients had more pulmonary co-morbidity. Dutch patients underwent more minimally invasive surgery and venous resections, but fewer multivisceral resections. No difference was found in rates of grade B/C postoperative pancreatic fistula, grade C postpancreatectomy haemorrhage and in-hospital mortality. There was more centralization in the Netherlands (1⋅3 versus 13⋅3 per cent of pancreatoduodenectomies in very low-volume centres; P < 0⋅001). In multivariable analysis, both hospital stay (difference 2⋅49 (95 per cent c.i. 1⋅18 to 3⋅80) days) and risk of reoperation (odds ratio (OR) 1⋅55, 95 per cent c.i. 1⋅22 to 1⋅97) were higher in the German audit, whereas risk of postoperative pneumonia (OR 0⋅57, 0⋅37 to 0⋅88) and readmission (OR 0⋅38, 0⋅30 to 0⋅49) were lower. Several baseline and surgical characteristics, including hospital volume, but not country, predicted mortality.Conclusion: This comparison of the German and Dutch audits showed variation in case mix, surgical technique and centralization for pancreatoduodenectomy, but no difference in mortality and pancreasspecific complications.

Treatment and survival of resected and unresected distal cholangiocarcinoma: a nationwide study

“…These differences are most likely explained by the generally worse outcomes in nationwide data compared to high-volume export centers. This has also been observed in a recent German nationwide study, reporting mortality rates of 8.6% for pancreatic malignant neoplasms and even 11.9% for nonpancreatic malignancies [25,26]. The median OS of patients with unresected nonmetastatic disease without and with chemotherapy (6.7 and 9.9 months) and of patients with metastatic disease without and with chemotherapy (2.8 and 8.2 months) are not in line with results from previous trials.…”

Centralizing a national pancreatoduodenectomy service: striking the right balance

“…As shown previously 11 , national 30‐ and 90‐day mortality rates were low in comparison with contemporary cohorts from Germany, France and the USA, and in line with rates reported from Sweden and the Netherlands 1,2,26–28 . Rates of any major complication, CR POPF and PPH grade C were equal to coeval cohorts from the USA, Netherlands and Germany 22,29,30 . The relaparotomy rate in the present cohort (18·1 per cent) was similar to, or somewhat higher than, that reported from other studies 22,30,31 .…”

“…Hospital units were dichotomized according to procedure volume, and defined as high volume for 40 or more procedures per year (1 unit) or as medium–low volume for fewer than 40 procedures per year (4 units). Others 3,5,6,22–24 have suggested this cut‐off, and it allowed for meaningful comparison within the Norwegian setting. Length of stay was defined conventionally as the number of postoperative nights spent at the hospital after the procedure, omitting any transfer and/or readmission stays.…”

Robotic Pancreatoduodenectomy: Patient Selection, Volume Criteria, and Training Programs

“…Based on this criteria we can built toward quality registries for RPD, such as recently started in Europe by the European Consortium on Minimally Invasive Pancreatic Surgery (E-MIPS; www.e-mips.com). Such quality registries, which already existed in separate countries (20) as Germany and the Netherlands can report on the outcomes of RPD and allows centers to reflect on their own outcomes in relation to those of others. These systems are highly supported by both the Miami guidelines and international organizations for hepato-pancreato-biliary (HPB) surgery.…”