Implementation of Minimally Invasive Pancreaticoduodenectomy at Low and High-Volume Centers

Abstract

BackgroundThere is a need to better define the safety of implementing the use of minimally invasive pancreaticoduodenectomy (MIPD) in order to provide evidence for safe application. The objective of this study was to evaluate the mortality associated with the implementation of MIPD across low and high-volume facilities using the National Cancer Database (NCDB). MethodsPatients in the NCDB with pancreatic cancer diagnosed from 2010-2016 undergoing MIPD were selected. Cumulative MIPD volume for each facility was calculated from the number of MIPD cases performed each year prior to and including the year of a patient's operation. A random effects logistic regression model was used to examine the adjusted association between log-transformed cumulative MIPD volume and 90-day mortality. ResultsAfter controlling for patient, tumor and facility-related variables, there was decreased 90-day mortality as the cumulative MIPD volume increased (OR 0.81; 95% CI 0.69-0.95; P = 0.009). Average annual open pancreaticoduodenectomy (PD) volume was independently protective throughout the implementation phase (OR 0.98; 95% CI 0.97-0.99; P = 0.049). This equates to an average predicted probability of 90-day mortality for the first 5 cumulative MIPD cases of 7.51% at a low-volume facility (5 open PDs per year) versus 4.39% at a high-volume facility (50 open PDs per year). ConclusionsUsing the NCDB, 90-day mortality following MIPD decreased with higher cumulative facility MIPD case volume. Although higher cumulative MIPD case volume was associated with reduced 90-day mortality at both low and high-volume facilities, the higher mortality during the implementation of MIPD is magnified at low-volume facilities. This retrospective analysis demonstrates that MIPD can be safely implemented with low mortality at facilities with high-volume open PD programs.