Building a hepato-pancreatico-biliary program in a community hospital: a preliminary analysis

Abstract

Objective: A hepatopancreaticobiliary program (HPBP) began at our academic-affiliated community teaching hospital in November 2014. Previously, most patients were referred to academic centers. This study evaluates our current progress. Methods: Elective HPB cases by two fellowship-trained surgical oncologists were prospectively tracked between 10/2012 and 8/2016. Procedure type, transfusions, length of stay (LOS), readmissions, morbidity and mortality were compared. Patients were grouped into pre-HPBP and post-HPBP. Analyses were run with SAS 9.4, with p<0.05 considered significant. Results: Operative volume increased significantly post-HPBP (22% versus 78%, p<0.0001), with 24 cases post-HPBP year 1, and 23 in the first 8 months of year 2. Pancreaticoduodenectomies (PD) (14% vs 37%) and distal pancreatectomies (DP) (14% vs 26%) increased significantly (p=0.0462). ICU admissions were similar between groups, but decreased between post-HPBP year 1 and 2 (OR 0.99, p=0.0493). Fewer pre-HPBP patients required transfusion, but transfusion volume was similar (2 vs 2.5 units, p=0.6089) between groups. Five (38%) pre-HPBP and 25 (53%) post-HPBP patients had complications (p=0.1464). Thirty-day readmissions rose from 0 to 4 (16.7%) post-HPBP (p=0.0690). Thirty-day mortality rose from 0 to 8.5% post-HPBP (p=0.5754), but all 4 died in the first 8 months (celiac artery thrombosis, CVA, hemorrhage, liver failure), 3 after PD. Post-HPBP year 2, 30-day mortality was 0, but 4.2% at 90 days (2: sepsis, recurrent anaplastic pancreatic cancer in HIV positive patient). Conclusion: The rapid growth of our HPBP revealed an unmet need for local services. The initial rise in mortality has declined, reflecting improved patient selection. Prospectively tracked data will improve outcomes and facilitate clinical pathways.