High-volume Pancreatic Surgery Centers Research Articles

The Financial Implications of Pancreatic Surgery: The Hospital Is the Big Winner, Not the Surgeon!

High-volume pancreatic surgery centers require a significant investment in expertise, time, and resources to achieve optimal patient outcomes. A detailed understanding of the economics of major pancreatic surgery is limited among many clinicians and hospital administrators. A greater consideration of these financial aspects may in fact have implications for enhancing clinical care and for a broader sustainability of high-volume pancreatic surgery programs. In this retrospective observational study, patients who underwent pancreaticoduodenectomy (PD), total pancreatectomy, or distal pancreatectomy at one academic medical center during the fiscal year 2021 were evaluated. Detailed hospital charges and professional fees were obtained for patients using the Qlik perioperative database. Clinical data for the study cohort were gathered from a prospectively maintained, IRB-approved pancreatic surgery database. Charges for the 91-day perioperative period were included. A P < 0.05 was considered significant. During the study period, 159 evaluable patients underwent 1 of 3 designated pancreatic resections included in the analysis. Ninety-seven patients (61%) were diagnosed with adenocarcinoma and 70% (n = 110) underwent PD. The total charges (combined professional and hospital charges) for the cohort encompassing the entire perioperative period were $20,661,759. The median charge per patient was $130,306 (interquartile range [IQR], $34,534). The median direct cost of care was $23,219 (IQR, $6321) and the median contribution margin per case was $10,092 (IQR, $22,949). The median surgeon professional fee charges were $7700 per patient (IQR, $1296) as compared to $3453 (IQR, $1,144) for professional fee receipts (45% of the surgeon charge). The differences between the professional fee charges and receipts per patient were also considerable for other health care professionals such as anesthesiologists ($4945 charges vs $1406 receipts [28%]) and pathologists ($3035 charges vs $680 receipts [22%]). The surgeon professional fees were only 6% of the total charges, while the professional fees for anesthesiology and pathology were 4% and 2% of the total charges, respectively. Supply charges were 3% of the total charges. Longer operative time was correlated with increased hospital and anesthesia charges, without a significant increase in surgeon charges (P < 0.001, P < 0.001, and P = 0.2, respectively). Male sex, diabetes, and low serum albumin correlated with greater total hospital charges (P = 0.01, P = 0.01, and P = 0.03, respectively). The role of the surgeon in the perioperative clinical care of major pancreatic resection patients is crucial and important and is by no means limited to the operative day. Nevertheless, in the context of the current US health care system, the reimbursement to the surgeon in the form of professional fees is a relatively small fraction of the total health care receipts for these patients. This imbalance necessitates a substantial financial partnership between hospitals and their pancreatic surgery units to ensure the long-term viability of these programs.

Simple Preoperative Imaging Measurements Predict Postoperative Pancreatic Fistula After Pancreatoduodenectomy.

Postoperative pancreatic fistula is a potentially devastating complication after pancreatoduodenectomy (PD). The purpose of this study was to identify features on preoperative computed tomography (CT) imaging that correlate with an increased risk of postoperative pancreatic fistula (POPF). Patients who underwent PD at our high-volume pancreatic surgery center from 2019 to 2021 were included if CT imaging was available within 8 weeks of surgical intervention. Pancreatic neck thickness (PNT), abdominal wall thickness (AWT), and intra-abdominal distance from pancreas to peritoneum (PTP) were measured by two board-certified radiologists who were blinded to the clinical outcomes. Radiographic measurements, as well as preoperative patient characteristics and intraoperative data, were assessed with univariate and multivariable analysis (MVA) to determine risk for clinically relevant POPF (CR-POPF, grades B and C). A total of 204 patients met inclusion criteria. Median PTP was 5.8cm, AWT 1.9 cm, and PNT 1.3 cm. CR-POPF occurred in 33 of 204 (16.2%) patients. MVA revealed PTP > 5.8 cm (odds ratio [OR] 2.86, p = 0.023), PNT > 1.3 cm (OR 2.43, p = 0.047), soft pancreas consistency (OR 3.47, p = 0.012), and pancreatic duct size ≤ 3.0 mm (OR 4.55, p = 0.01) as independent risk factors for CR-POPF after PD. AWT and obesity were not associated with increased risk of CR-POPF. Patients with PTP > 5.8cm or PNT > 1.3cm were significantly more likely to suffer a major complication after PD (39.6% vs. 22.3% and 40% vs. 22.1%, p < 0.008). Patients with a thick pancreatic neck and increased intra-abdominal girth have a heightened risk of CR-POPF after pancreatoduodenectomy, and they experience more serious postoperative complications. We defined a simple CT scan-based measurement tool to identify patients at increased risk of CR-POPF.

Arterial Resection for Pancreatic Cancer: Feasibility and Current Standing in a High-Volume Center.

Arterial resection (AR) during pancreatectomy for curative R0 resection of pancreatic ductal adenocarcinoma (PDAC) remains a controversial procedure with high morbidity. To investigate the feasibility and oncological outcomes of pancreatectomy combined with AR at a high-volume center for pancreatic surgery. We retrospectively analyzed our experience in PDAC patients, who underwent pancreatic resection with AR and/or venous resection (VR) between 2007 and 2021. In total 259 PDAC patients with borderline resectable (n = 138) or locally advanced (n = 121) PDAC underwent vascular resection during tumor resection. From these, 23 patients had AR (n = 4 due to intraoperative injury, n = 19 due to suspected arterial infiltration). However, 12 out of 23 patients (52.2%) underwent simultaneous VR including 1 case with intraoperative arterial injury. In comparison, 11 patients (47.8%) underwent AR only including 3 intraoperative arterial injury patients. Although the operation time and bleeding rate of patients with AR were respectively longer and higher than in VR, no significant difference was detected in postoperative complications between VR and AR (P = 0.11). The final histopathological findings of PDAC patients were similar, including M stage, regional lymph node metastases, and R0 margin resection. The mortality of the entire cohort was 6.2% (16/259), with a tendency to increase mortality in the AR cohort, yet without statistical significance (VR: 5% vs AR: 21.1%; P = 0.05). Although 19 (82.6%) patients had PDAC in the final histopathology, only 6 were confirmed to have infiltrated arteria. The microscopic distribution of PDAC in these infiltrated arterial walls on hematoxylin-eosin staining was classified into 3 patterns. Strikingly, the perivascular nerves frequently exhibited perineural invasion. AR can be performed in high-volume centers for pancreatic surgery with an acceptable morbidity, which is comparable to that of VR. However, the likelihood of arterial infiltration seems to be rather overestimated, and as such, AR might be avoidable or replaced by less invasive techniques such as divestment during PDAC surgery.

Open-label, single arm phase II trial investigating the efficacy, safety and quality of life of neoadjuvant chemotherapy with liposomal irinotecan combined with oxaliplatin and 5-fluorouracil/folinic acid followed by curative surgical resection in patients with hepatic oligometastatic adenocarcinoma of the pancreas (HOLIPANC).

TPS4193 Background: As of today, the recommendation for patients with adenocarcinoma of the pancreas and hepatic metastases is systemic chemotherapy alone regardless of the number and location of metastases. In the past, case reports have repeatedly reported survival data of patients who received metastatic and primary tumor resection outside the guidelines. However, there are currently no controlled clinical data from prospective studies that have evaluated the effectiveness of systemic chemotherapy in combination with tumor and metastasis resection in the context of hepatic oligometastasis in pancreatic cancer. Methods: In this single arm, phase-2 trial, survival data from patients receiving neoadjuvant chemotherapy followed by R0/R1 resection will be compared to historic data from patients with oligometastatic adenocarcinoma of the pancreas. Inclusion criteria are patients with a maximum of 5 liver metastases and histology proven PDAC. The combination of liposomal irinotecan (nal-IRI), oxaliplatin (OX) and 5-fluouracil (5-FU)/folinic acid (FA) (Nal-IRIFOX) was chosen as neoadjuvant chemotherapy since recent data suggested superior efficacy and less toxicity compared to mFOLFIRINOX. The primary endpoint is overall survival (OS) after R0/R1 resection. Secondary efficacy endpoints are R0/R1 resection rate and progression-free survival (PFS). Secondary safety endpoints are type, frequency and severity of adverse events with severity according to NCI CTCAE version 5.0 and perioperative morbidity and mortality. Eligible patients with hepatic oligometastatic adenocarcinoma of the pancreas will receive neoadjuvant combination chemotherapy in cycles of 14 days for a duration of 16 weeks in total. In patients with progressive disease during or after the first 4 cycles, neoadjuvant chemotherapy will be permanently discontinued. Patients with tumor response or stable disease after the first 4 cycles according to RECIST v1.1 but a non-resectable primary tumor will receive 4 more cycles. Patients with tumor response or stable disease and a resectable primary tumor after the first 4 cycles will undergo explorative laparotomy and synchronous resection of the tumor and hepatic metastases, if feasible. In total 150 patients will be enrolled for this trial with an aim of 55 patients receiving a complete macroscopic synchronous tumor and metastatic resection. The study is currently ongoing on 11 high-volume centers for pancreatic surgery within Germany. This is the first clinical study to prospectively evaluate the value of multimodality therapy concepts in oligometastatic pancreatic cancer. Clinical trial information: NCT04617457 .

Distal Pancreatectomy: Extent of Resection Determines Surgical Risk Categories.

Recently, subclassification of pancreatoduodenectomy in 4 differing types has been reported, because additional major vascular and multivisceral resections have been shown to be associated with an increased risk of postoperative morbidity and mortality. To classify distal pancreatectomy (DP) based on the extent of resection and technical difficulty and to evaluate postoperative outcomes with regards to this classification system. All consecutive patients who had undergone DP between 2001 and 2020 in a high-volume pancreatic surgery center were included in this study. DPs were subclassified into 4 distinct categories reflecting the extent of resection and technical difficulty, including standard DP (type 1), DP with venous (type 2), multivisceral (type 3), or arterial resection (type 4). Patient characteristics, perioperative data, and postoperative outcomes were analyzed and compared among the 4 groups. A total of 2135 patients underwent DP. Standard DP was the most frequently performed procedure (64.8%). The overall 90-day mortality rate was 1.6%. Morbidity rates were higher in patients with additional vascular or multivisceral resections, and 90-day mortality gradually increased with the extent of resection from standard DP to DP with arterial resection (type 1: 0.7%; type 2: 1.3%; type 3: 3%; type 4: 8.7%; P <0.0001). Multivariable analysis confirmed the type of DP as an independent risk factor for 90-day mortality. Postoperative outcomes after DP depend on the extent of resection and correlate with the type of DP. The implementation of the 4-type classification system allows standardized reporting of surgical outcomes after DP improving comparability of future studies.

Response to: Comment on: Pancreatectomy With Islet-Autotransplantation as Alternative for Pancreato-Duodenectomy in Patients With a High-Risk for Postoperative Pancreatic Fistula: The Jury Is Still Out.

We thank Dr Thomas Frederik Stoop and colleagues for their keen interest in our study1 and their words of appreciation for our work. The first issue raised by the authors relates to the risk–benefit balance of total pancreatectomy associated with islet-autotransplantation (TP-IAT) versus pancreatoduodenectomy (PD). As for whether postoperative morbidity is the ideal endpoint for our trial, we point out that the 90-day overall complication rate is the standard primary endpoint of many studies on this topic. Furthermore, as for our trial is concerned, it was an unavoidable choice to ensure study feasibility. In facts, considering the 90-day mortality rate as primary outcome, 464 patients would be needed to detect a statistical difference with adequate power, an unrealistic sample size for a prospective randomized trial on autologous islet transplantation in candidates for pancreatic surgery and at high risk for POPF. Consequently, overall, disease-specific and disease-free survival were included as secondary endpoints. However, the point raised by Stoop and colleagues actually implies a question that goes beyond the results of our trial, namely whether primary total pancreatectomy (TP) in patients at high risk of POPF is justified and preferable to pancreaticoduodenectomy. This question is still very open, and our results suggest that there may be room for an approach based on TP. In our study, as in other recent retrospective single-center series,2-3 a 2%–4% mortality rate after TP is reported and, even in daily clinical practice, the 90-day mortality rate was 4% in centers performing more than 60 PDs per year.4 We are aware of and appreciate the results of the Dutch PORSCH trial, but that study population was not selected for being at high risk of POPF, and therefore, the results of PORSCH cannot be extrapolated to the patients enrolled in our study. A major contribution to the discussion on this topic will be hopefully provided by the recently initiated TETRIS study (NCT05212350), a multicenter RCT in a cohort of patients with a very high risk of POPF, comparing TP and primary pancreatic anastomosis for postoperative outcomes and quality of life. The second issue raised is related to the patient-reported outcomes. We fully agree that quality of life overtime is a highly relevant endpoint when determining the impact of TP on the life of our patients and their families. However, our study was not an appropriate setting to provide meaningful data on this issue. In fact, the heterogeneity of the underlying pancreatic diseases in terms of disease severity and the various adjuvant treatments patients had faced for extended periods of time after surgery were likely to have had a significant impact on patients’ relevant outcomes. The third issue relates to the relevance of glucose control. Islet-autotransplantation resulted in at least partial endogenous insulin secretion in around 90% of patients undergoing TP and good metabolic control at the last follow-up [day 388 (235–1307)] in 62% of the patients without severe hypoglycemic episodes or diabetes-related mortality. We were impressed by the recent results of the Dutch Pancreatic Cancer Group using a bihormonal artificial pancreas in 12 patients after TP. The 7-day follow-up in 9 of the 12 patients who completed the study showed an increased time spent between 70 and 180 mg/dL (time in range) of glucose levels. We hope these data will be confirmed through larger and longer RCTs involving unselected patients who underwent TP. We envision islet transplantation not as an alternative to the use of exogenous insulin and glucose sensor or delivery technology in patients with TP, but as a complementary and synergistic treatment for diabetes following TP since the bihormonal artificial pancreas hopefully wish to perform even better in patients with autologous islet transplantation after TP. We completely agree with Stoop and colleagues that the jury is still out. However, our study confirmed that IAT is a feasible choice in patients with pancreas diseases other than chronic pancreatitis, and this should be viewed as an important advance in the field. The decision to perform TP-IAT requires assessing the risk–benefit ratio of this procedure in each individual case and should be discussed with the candidate patient in the context of multidisciplinary teams. High-volume referral centers for pancreatic surgery should be encouraged to collaborate with an islet isolation facility to provide access to IAT when appropriate. At last, in our conclusion, we used “may” to convey a degree of uncertainty. The results of our study are not a final ruling and we hope the jury is still out also for Stoop and colleagues in their appreciation for the potentials of TP-IAT.

Blueprint for safe transition from a low- to high-volume pancreatic surgery center

We describe a straightforward model to implement a high volume specialty surgery program at a community hospital. Using pancreatic surgery as an example, we employed published processes in three arenas. First, mandatory multidisciplinary tumor board presentations captured all the patients considered for surgery. Then, perioperative protocols using tools such as enhanced recovery and teamwork in the perioperative arena created a reproducible and safe environment for complex surgery. We critically reviewed all complications using the Clavien-Dindo methodology, and confirmed our favorable outcomes via the targeted NSQIP program. These standard steps can be used for implementation of a new complex surgical procedure.

Robotic versus Open Pancreatoduodenectomy for Pancreatic and Periampullary Tumors (PORTAL): a study protocol for a multicenter phase III non-inferiority randomized controlled trial

BackgroundPancreatoduodenectomy is a complex and challenging procedure that requires meticulous tissue dissection and proficient suturing skills. Minimally invasive surgery with the utilization of robotic platforms has demonstrated advantages in perioperative patient outcomes in retrospective studies. The development of robotic pancreatoduodenectomy (RPD) in specific has progressed significantly, since first reported in 2003, and high-volume centers in pancreatic surgery are reporting large patient series with improved pain management and reduced length of stay. However, prospective studies to assess objectively the feasibility and safety of RPD compared to open pancreatoduodenectomy (OPD) are currently lacking.Methods/designThe PORTAL trial is a multicenter randomized controlled, patient-blinded, parallel-group, phase III non-inferiority trial performed in seven high-volume centers for pancreatic and robotic surgery in China (> 20 RPD and > 100 OPD annually in each participating center). The trial is designed to enroll and randomly assign 244 patients with an indication for elective pancreatoduodenectomy for malignant periampullary and pancreatic lesions, as well as premalignant and symptomatic benign periampullary and pancreatic disease. The primary outcome is time to functional recovery postoperatively, measured in days. Secondary outcomes include postoperative morbidity and mortality, as well as perioperative costs. A sub-cohort of 128 patients with pancreatic adenocarcinoma (PDAC) will also be compared to assess the percentage of patients who undergo postoperative adjuvant chemotherapy within 8 weeks, in each arm. Secondary outcomes in this cohort will include patterns of disease recurrence, recurrence-free survival, and overall survival.DiscussionThe PORTAL trial is designed to assess the feasibility and safety of RPD compared to OPD, in terms of functional recovery as described previously. Additionally, this trial will explore whether RPD allows increased access to postoperative adjuvant chemotherapy, in a sub-cohort of patients with PDAC.Trial registrationClinicalTrials.govNCT04400357. Registered on May 22, 2020

Is Improved Survival in Early-Stage Pancreatic Cancer Worth the Extra Cost at High-Volume Centers?

Volume of operative cases may be an important factor associated with improved survival for early-stage pancreatic cancer. Most high-volume pancreatic centers are also academic institutions, which have been associated with additional healthcare costs. We hypothesized that at high-volume centers, the value of the extra survival outweighs the extra cost. This retrospective cohort study used data from the California Cancer Registry linked to the Office of Statewide Health Planning and Development database from January 1, 2004 through December 31, 2012. Stage I-II pancreatic cancer patients who underwent resection were included. Multivariable analyses estimated overall survival and 30-day costs at low- vs high-volume pancreatic surgery centers. The incremental cost-effectiveness ratio (ICER) and incremental net benefit (INB) were estimated, and statistical uncertainty was characterized using net benefit regression. Of 2,786 patients, 46.5% were treated at high-volume centers and 53.5% at low-volume centers. There was a 0.45-year (5.4 months) survival benefit (95% CI 0.21-0.69) and a $7,884 extra cost associated with receiving surgery at high-volume centers (95% CI $4,074-$11,694). The ICER was $17,529 for an additional year of survival (95% CI $7,997-$40,616). For decision-makers willing to pay more than $20,000 for an additional year of life, high-volume centers appear cost-effective. Although healthcare costs were greater at high-volume centers, patients undergoing pancreatic surgery at high-volume centers experienced a survival benefit (5.4 months). The extra cost of $17,529 per additional year is quite modest for improved survival and is economically attractive by many oncology standards.

Effects of COVID-19 Pandemic on the Treatment of Pancreatic Cancer: A Perspective from Central Europe

Background: This survey aimed to register changes determined by the COVID-19 pandemic on pancreatic surgery in a specific geographic area (Germany, Austria, and Switzerland) to evaluate the impact of the pandemic and obtain interesting cues for the future. Methods: An online survey was designed using Google Forms focusing on the local impact of the pandemic on pancreatic surgery. The survey was conducted at 2 different time points, during and after the lockdown. Results: Twenty-five respondents (25/56) completed the survey. Many aspects of oncological care have been affected with restrictions and delays: staging, tumor board, treatment selection, postoperative course, adjuvant treatments, outpatient care, and follow-up. Overall, 60% of respondents have prioritized pancreatic cancer patients according to stage, age, and comorbidities, and 40% opted not to operate high-risk patients. However, for 96% of participants, the standards of care were guaranteed. Discussion/Conclusions: The first wave of the COVID-19 pandemic had an important impact on pancreatic cancer surgery in central Europe. Guidelines for prompt interventions and prevention of the spread of viral infections in the surgical environment are needed to avoid a deterioration of care in cancer patients in the event of a second wave or a new pandemic. High-volume centers for pancreatic surgery should be preferred and their activity maintained. Virtual conferences have proven to be efficient during this pandemic and should be implemented in the near future.

Robotic vs open distal pancreatectomy: A multi-institutional matched comparison analysis.

Pancreatic surgery is still a challenge even in high-volume centers. Clinically relevant postoperative pancreatic fistula (CR-POPF) represents the greatest contributor to major morbidity and mortality, especially following pancreatic distal resection. In this study, we compared robotic distal pancreatectomy (RDP) to open distal pancreatectomy (ODP) in terms of CR-POPF development and analyzed oncologic efficacy of RDP in the subgroup of patients with pancreatic ductal adenocarcinoma (PDAC). We collected data from five high-volume centers for pancreatic surgery and performed a matched comparison analysis to compare short and long-term outcomes after ODP or RDP. Patients were matched with a 2:1 ratio according to age, ASA (American Society of Anesthesiologists) score, body mass index (BMI), final pathology, and TNM (Tumour, Node, Metastasis) staging system VIII ed. Two hundred and forty-six patients who underwent 82 RDPs and 164 ODPs were included. No differences were found in the incidence of CR-POPF. In the PDAC group, median DFS and OS were 10.8months and 14.8months in the ODP group and 10.4months and 15months in the RDP group, respectively. Robotic distal pancreatectomy is a safe surgical strategy for PDAC and incidence of CR-POPF is equivalent between RDP and ODP. RDP should be considered equivalent to ODP in terms of oncological efficacy when performed in high-volume and proficient centers.

Minimally Invasive Pancreaticoduodenectomy in Elderly Patients: Systematic Review andMeta-Analysis.

Minimally invasive pancreaticoduodenectomy (MIPD) for pancreatic head or periampullary lesions is being utilized with increasing frequency. However, few data are available for the elderly. The objective of this study is to assess the safety and feasibility of MIPD in elderly population, by making a comparison with conventional open pancreaticoduodenectomy (OPD) and with non-elderly population. We conducted a systematic search to identify all eligible studies in Cochrane Library, Ovid, and PubMed from their inception up to April 2020. Seven retrospective studies involving 2727 patients were included. Of these, 3 compared MIPD and OPD in elderly patients, 2 compared MIPD in elderly and non-elderly patients, and 2 included both outcomes. Compared to those with OPD, elderly patients who underwent MIPD were associated with less 90-day mortality (OR 0.56, 95% CI 0.32-0.97; P = 0.04) and fewer delayed gastric emptying (OR 0.54, 95% CI 0.33-0.88; P = 0.01). On the other hand, no significant difference was observed in terms of 30-day mortality, major morbidity, postoperative pancreatic fistula (grade B/C), postoperative hemorrhage, reoperation, 30-day readmission, and operative time. For patients who have treated with MIPD, elderly did not reveal worse outcomes than non-elderly. MIPD is a safe and feasible procedure for select elderly patients if performed by experienced surgeons from high-volume pancreatic surgery centers. However, further randomized studies are required to confirm this.

Facility volume-survival relationship in patients with early-stage pancreatic adenocarcinoma treated with neoadjuvant chemotherapy followed by pancreatoduodenectomy

BackgroundThere is evidence that neoadjuvant therapy is associated with improved survival compared with upfront pancreatectomy for pancreatic adenocarcinoma. Treatment at high-volume pancreatic surgery centers is associated with improved short-term postoperative outcomes compared with low-volume centers. We compared overall survival of patients with early-stage pancreatic adenocarcinoma who received neoadjuvant therapy before resection stratified by facility volume. MethodsPatients with clinical T0 to T2 pancreatic adenocarcinoma who received neoadjuvant therapy before pancreatoduodenectomy were identified in the National Cancer Database (2010–2016). High-volume pancreatic surgery centers performed ≥36 pancreatectomies/year. Patients were matched 1:1 by propensity score. Pathologic outcomes, postoperative outcomes, and overall survival were compared. ResultsBefore matching, 1,449 patients were treated at low-volume centers and 250 at high-volume pancreatic surgery centers. After matching, there were 177 patients per group. High-volume pancreatic surgery centers were more commonly academic/research facilities (99.4% vs 54.0%; P < .001), and patients traveled greater distances (65 vs 13 miles; P < .001). Time from diagnosis to neoadjuvant therapy and surgery was similar. Treatment at high-volume pancreatic surgery centers was associated with shorter duration of stay (7 vs 8 days; P = .003) and lower 90-day mortality rate after pancreatoduodenectomy (0.0% vs 5.0%; P = .01). Patients treated at high-volume pancreatic surgery centers had improved overall survival (36.3 vs 29.4 months; P = .03; hazard ratio 0.73). On subset analysis of academic/research facilities, high-volume pancreatic surgery centers remained associated with shorter duration of stay, lower 90-day mortality, and greater overall survival. ConclusionThe majority of patients treated with neoadjuvant therapy for early-stage pancreatic adenocarcinoma received care at low-volume centers. Treatment at high-volume pancreatic surgery centers was associated with improved overall survival and short-term postoperative outcomes.

Regionalization of pancreatic cancer treatment within an integrated healthcare system

Presenter: Diana Hsu MD | University of California, San Francisco Background: Studies have shown that pancreaticoduodenectomies performed at higher volume centers result in decreased mortality, length of stay, operating time, and cost compared to those performed at lower volume centers. Kaiser Permanente Northern California (KPNC) implemented regionalization of pancreatic cancer care to Centers of Excellence (CoE) within its integrated healthcare system. This study examines the survival outcomes after the regionalization of care. Methods: A retrospective chart review of 1621 patients undergoing pancreatic cancer treatment from February 2010 and December 2018 was performed. The transitions from 21 hospitals to 4 Centers of Excellence (CoE) included creating high volume pancreatic surgery centers (>25 pancreatic resections per year) and designated specialties, such as medical oncology, radiology, radiation oncology, and pathology. Descriptive statistics were performed, followed by bivariate analysis to assess differences in characteristics according to either the independent or dependent variables. Given that all variables assessed were categorical, Chi squared tests were used to determine differences of statistical significance. Unadjusted and adjusted survival analyses were performed using Kaplan–Meier. Cox proportional hazard regression models were used to determine the association between race and ethnicity and the primary outcome (overall survival in months). All statistical analyses were performed by SPSS version 22. Results: There was no difference in baseline demographics among patients undergoing pancreatic cancer treatment pre and post-regionalization. However, there was a statistically significant difference in pre and post-regionalization number of patients who had 16 or more lymph nodes sampled, 142 (44%) and 219 (69%), respectively (p<.001). There was also an increase in neoadjuvant chemotherapy utilization from 10% to 31%, pre and post-regionalization. The median overall survival (OS) pre and post-regionalization was 11 and 14 months, respectively (p<.001). (Fig 1) Median follow up of patients was 32 months. Conclusion: Regionalization of pancreatic cancer care at KPNC, an integrated hospital system, resulted in improvements in surgical quality outcomes, such as adequate lymph node sampling. Our multidisciplinary approach to CoE encompasses standardization and performance improvements in oncology, radiology, pathology, as well as surgery. The results suggest that regionalization of care in a large integrated healthcare system improves overall survival for patients undergoing pancreatic cancer treatment.

State-of-the-Art and Development Trends of Minimally Invasive Pancreatic Surgery

Compared with traditional surgery, minimally invasive surgery has the advantages of less complications and quick postoperative recovery. Therefore, modern surgery is developing towards the direction of minimally invasive. while minimally invasive pancreatic surgeries are rather challenging and develop slowly, due to the limits with different operation techniques, long operation time and different operation outcomes, which are only carried out in high-volume pancreatic surgery centers. This special coverage topic will elaborate our long-term experience and the key points to overcome the operational difficulties in laparoscopic and robotic pancreas surgery. In order to promote the development of minimally invasive pancreatic technology and benefit more patients (especially pancreatic cancer patients), some suggestions and prospects with the latest research results at home and abroad are put forward for the future development of this field.

Racial/ethnic disparities in the use of high-volume centers for hepatobiliary and pancreatic cancer surgery.

457 Background: The impact of hospital volume on the outcomes of cancer surgery has been well established. The present studies investigates how race/ethnicity influences the utilization of high-volume centers for hepatobiliary and pancreatic surgery. Methods: Patients that underwent surgery for hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (ICC), extrahepatic cholangiocarcinoma (ECC), ampullary adenocarcinoma (AC), or pancreatic ductal adenocarcinoma (PDAC) between 2006 and 2015 were identified from the National Cancer Data Base. Hospitals were divided into low- and high-volume centers based on the medium number of cancer surgeries per year. Multivariable logistic regression analyses predicting receipt of care at a low-volume center based on age, sex, race/ethnicity, comorbidities, insurance, income, travel distance, geographic location, urban/metro location, and tumor stage were performed. All analyses were performed separately by tumor type. Results: 8,962 patients with HCC, 2,119 with ICC, 3,973 with ECC, 5,125 with AC, and 25,231 with PDAC were identified. Non-Hispanic black patients were more likely to undergo resection for AC (vs. non-Hispanic white: AOR, 1.326; p = 0.0125) or PDAC (vs. non-Hispanic white: AOR, 1.187; p = 0.0002) at a low volume centers. Hispanic patients more often underwent surgery for ECC (vs. non-Hispanic white: AOR, 1.731; p &lt; 0.0001) or PDAC (vs. non-Hispanic white: 2.030; p &lt; 0.0001) cancer at a low-volume center. Patients of Asian descent were significantly less often treated for HCC at a low volume center (vs. non-Hispanic white: AOR, 0.644; p &lt; 0.0001) compared to non-Hispanic whites. Non-Hispanic black, Hispanic, or Asian race/ethnicity did not impact the likelihood of receiving care at a low volume center for any other tumor types. Conclusions: The results of this study suggest that race/ethnicity influences the likelihood of receiving care at a high-volume cancer center, even after controlling for other barriers to access to care, including insurance status, income and travel distance.

Ultrasound-Guided Robotic Enucleation of Pancreatic Neuroendocrine Tumors.

Pancreatic neuroendocrine tumors (PanNETs) are relatively rare neoplasms with a low to mild malignant potential. They can be further divided into functioning and nonfunctioning, according to their secretive activity. Surgery is an optimal approach, but the classic open approach is challenging, with some patients having long hospitalization and potentially life-threatening complications. The robotic approach for PanNETs may represent an option to optimize their management. We retrospectively reviewed our prospectively maintained databases from 2 high-volume Italian centers for pancreatic surgery. Demographics, pathological characteristics, perioperative outcome, and medium-term follow-up of patients who underwent robotic pancreatic enucleations were collected. Twelve patients with final diagnosis of PanNET were included. The mean age of the patients was 53.8 years (25-77). The median body mass index was 26 (24-29). Three lesions were functioning insulinomas, while the others were nonfunctioning tumors. No deaths occurred. Mild postoperative complications occurred, except for 1 grade B pancreatic fistula. The mean postoperative stay was 3.9 days (2-5). Our results confirm that robotic enucleation is a feasible and safe approach for the treatment of PanNETs, with short hospital stay and low incidence of morbidity.

Total parenteral nutrition in patients following pancreaticoduodenectomy: lessons from 1184 patients

BackgroundTotal parenteral nutrition (TPN) has historically been used conservatively in the management of patients after pancreaticoduodenectomy (PD). Herein, we evaluate the indications for and outcomes associated with TPN use in a high-volume pancreatic surgery center. Materials and methodsWe retrospectively queried our institution's pancreatic surgery database for patients who received TPN after PD from 2006 through 2015. ResultsOf 1184 patients who underwent PD, 232 (19.6%) received TPN perioperatively. The most common indications for TPN were delayed gastric emptying (DGE, n = 171, 73.7%), pancreatic fistula (n = 102, 44%), and generalized malnutrition (n = 25, 10.8%). The median day of TPN initiation was postoperative day 4 (range: −31 to 22), with a median usage of 9 days (range: 1-115). Forty-four (19%) patients received short-course TPN (≤3 days), primarily those diagnosed with isolated grade A DGE without associated complications (P = 0.0003). Multivariate analysis suggests the presence of deep surgical site infection (odds ratio: 3.09, [1.16-5.06], P = 0.018) or pancreatic fistula (odds ratio: 2.57, [1.03-6.41], P = 0.043) at the time of DGE presentation as predictive of long-term TPN requirement. Hyperglycemia (34.5%) was the most common complication resulting from TPN use, whereas central line–associated bloodstream infections (2.6%) were rare. Readmissions (35.3% TPN cohort; 15% historical institutional rate) were most commonly due to poor oral intake (26.8%). The 30-day mortality rate in the overall TPN cohort was 3.4% (0.8% historical institutional rate). ConclusionsTPN is a critical and safe adjunct for patients who develop PD-associated complications; however, it may be of limited utility for patients with isolated DGE.

Pathologic assessment of vascular involvement in pancreatectomy with vascular resection: room for improvement

Objective: Pancreatectomy with vein resection is commonly performed. No standard in pathologic reporting currently exists with respect to vascular involvement. We have observed wide variability in pathologic interpretation of pancreatectomy specimens that include vein resection, and hypothesized that this variability existed in a multi-institutional setting. Methods: A retrospective review of pancreatectomy/venous resection patients treated within a multi-center pancreas surgery consortium. Pathology reports were reviewed for documentation of vascular margins. For this study's purpose, complete pathologic assessment of vascular margin was defined to include presence/absence of invasion, depth of invasion, radial involvement and longitudinal involvement. Results: Among 1341 pancreatectomies performed for malignancy, 136 (10.1%) included venous resection. Operations included pancreatoduodenectomy (n=105, 77%), total pancreatectomy (n=21, 22%), and distal pancreatectomy (n=10, 7%). Veins resected were: portal vein (n=70, 51%), superior mesenteric vein (n=41, 30%), and portomesenteric confluence (n=13, 10%). Twenty-three of the pathology reports (17%) made no mention of any vascular segment in the specimen. Nearly half of the reports (n=60, 44%) contained no comment on the vascular radial margin. Ninety-nine reports (72% of total) commented on vascular invasion; complete pathologic assessment of the vascular margin was described in only 17%. Discrete histologic depth of invasion was described in 32% of the reports. Conclusion: Complete pathologic evaluation of vascular margins in pancreatectomy with vascular resection specimens is poor, even at high-volume pancreatic surgery centers. Improving communication between surgeons and pathologists and developing a standardized pathology reporting system will permit more complete understanding of the natural history of this patient population.

Pancreatogastrostomy Versus Pancreatojejunostomy for RECOnstruction After PANCreatoduodenectomy (RECOPANC, DRKS 00000767): Perioperative and Long-term Results of a Multicenter Randomized Controlled Trial.

Objectives:To assess pancreatic fistula rate and secondary endpoints after pancreatogastrostomy (PG) versus pancreatojejunostomy (PJ) for reconstruction in pancreatoduodenectomy in the setting of a multicenter randomized controlled trial.Background:PJ and PG are established methods for reconstruction in pancreatoduodenectomy. Recent prospective trials suggest superiority of the PG regarding perioperative complications.Methods:A multicenter prospective randomized controlled trial comparing PG with PJ was conducted involving 14 German high-volume academic centers for pancreatic surgery. The primary endpoint was clinically relevant postoperative pancreatic fistula. Secondary endpoints comprised perioperative outcome and pancreatic function and quality of life measured at 6 and 12 months of follow-up.Results:From May 2011 to December 2012, 440 patients were randomized, and 320 were included in the intention-to-treat analysis. There was no significant difference in the rate of grade B/C fistula after PG versus PJ (20% vs 22%, P = 0.617). The overall incidence of grade B/C fistula was 21%, and the in-hospital mortality was 6%. Multivariate analysis of the primary endpoint disclosed soft pancreatic texture (odds ratio: 2.1, P = 0.016) as the only independent risk factor. Compared with PJ, PG was associated with an increased rate of grade A/B bleeding events, perioperative stroke, less enzyme supplementation at 6 months, and improved results in some quality of life parameters.Conclusions:The rate of grade B/C fistula after PG versus PJ was not different. There were more postoperative bleeding events with PG. Perioperative morbidity and mortality of pancreatoduodenectomy seem to be underestimated, even in the high-volume center setting.