Defining Volume Targets for Regionalization of Pancreaticoduodenectomy, Esophagectomy, and Major Lung Resection Centers to Improve Oncologic and Surgical Outcomes.

BACKGROUND: Performance of complex cancer surgeries at high-volume (HV) centers has been shown to reduce operative mortality. However, the case volume threshold that should be used to define HV centers is unknown. In this study, we determined thresholds to define HV pancreaticoduodenectomy, esophagectomy, and major lung resection centers based on clinical parameters. Then, we assessed the association of hospital volume with oncologic outcomes and overall survival. METHODS: We identified adult NCDB patients undergoing pancreaticoduodenectomy, esophagectomy, and major lung resections between 2004 and 2015. Multivariable models with restricted cubic splines were built to predict 5-year overall survival for each surgery group according to average yearly case volume, adjusting for demographic and clinicopathologic factors. The change point procedure was then used to identify volume cut-points for each surgery type. RESULTS: We identified the following thresholds to define HV status: 25 cases/year for pancreaticoduodenectomy; 18 cases/year for esophagectomy; and 54 cases/year for major lung resections. For all surgery types, treatment at a HV center was associated with an increased likelihood of R0 resection and adequate lymph node evaluation. HV centers had significantly decreased 30- and 90-day, postoperative mortality after adjusting for age, sex, race, comorbidities, histology, and stage. An overall survival benefit also was observed for patients undergoing resections at HV centers. CONCLUSIONS: Using novel methodology, our study identified volume thresholds for HV pancreaticoduodenectomy, esophagectomy, and major lung resection centers that were associated with improved oncologic outcomes and overall survival. These definitions of HV centers should be considered when evaluating regionalization of complex cancer care.

Minimally invasive pancreaticoduodenectomy: A favorable approach for frail patients with pancreatic cancer.

BACKGROUND: Within the past decade, minimally invasive pancreaticoduodenectomy has been increasingly adopted in high-volume cancer centers. Amid broader trends of a growing older population, the numbers of frail patients with cancer are expected to increase. In this study, we compared the postoperative outcomes of open pancreaticoduodenectomy and minimally invasive pancreaticoduodenectomy in frail patients with pancreatic ductal adenocarcinoma. METHODS: Using the pancreatectomy-targeted American College of Surgeons-National Surgical Quality Improvement Program database (2014-2021), we identified pancreaticoduodenectomy cases for pancreatic ductal adenocarcinoma. Patients with a modified frailty index ≥2 were considered frail. We performed 2:1 (open pancreaticoduodenectomy to minimally invasive pancreaticoduodenectomy) optimal pair propensity score matching for both patient- and disease-specific characteristics. We evaluated baseline covariate balance for homogeneity and assessed 30-day postoperative outcomes: complications, discharge destination, major morbidity, and mortality. RESULTS: We identified 3,143 frail patients who underwent pancreaticoduodenectomy for pancreatic ductal adenocarcinoma. Of those, 275 (9%) underwent minimally invasive pancreaticoduodenectomy. Minimally invasive pancreaticoduodenectomy was associated with a lower rate of any complications compared with open pancreaticoduodenectomy (43% vs 54%; P < .001), major morbidity (29% vs 35%; P = .042), and nonhome discharge (12% vs 17%; P = .022). When comparing the 2 minimally invasive pancreaticoduodenectomy approaches, robotic surgery was associated with fewer complications compared with laparoscopy (39% vs 51%; P = .040) and a lower mortality rate (1% vs 4%; P = .041) CONCLUSION: In frail patients with pancreatic cancer, minimally invasive pancreaticoduodenectomy was associated with better postoperative outcomes than open pancreaticoduodenectomy. This study builds on growing literature reporting that, when properly implemented, minimally invasive pancreaticoduodenectomy is associated with more favorable postoperative outcomes. Given the particularly high risk of complication in frail patients, implementing a preoperative frailty assessment can provide valuable insights to inform patient counseling.