Cost-effectiveness of robotic vs laparoscopic distal pancreatectomy. Results from the national prospective trial ROBOCOSTES.

INTRODUCTION: Although several studies report that the robotic approach is more costly than laparoscopy, the cost-effectiveness of robotic distal pancreatectomy (RDP) over laparoscopic distal pancreatectomy (LDP) is still an issue. This study evaluates the cost-effectiveness of the RDP and LDP approaches across several Spanish centres. METHODS: This study is an observational, multicenter, national prospective study (ROBOCOSTES). For one year from 2022, all consecutive patients undergoing minimally invasive distal pancreatectomy were included, and clinical, QALY, and cost data were prospectively collected. The primary aim was to analyze the cost-effectiveness between RDP and LDP. RESULTS: During the study period, 80 procedures from 14 Spanish centres were analyzed. LDP had a shorter operative time than the RDP approach (192.2 min vs 241.3 min, p = 0.004). RDP showed a lower conversion rate (19.5% vs 2.5%, p = 0.006) and a lower splenectomy rate (60% vs 26.5%, p = 0.004). A statistically significant difference was reported for the Comprehensive Complication Index between the two study groups, favouring the robotic approach (12.7 vs 6.1, p = 0.022). RDP was associated with increased operative costs of 1600 euros (p < 0.031), while overall cost expenses resulted in being 1070.92 Euros higher than the LDP but without a statistically significant difference (p = 0.064). The mean QALYs at 90 days after surgery for RDP (0.9534) were higher than those of LDP (0.8882) (p = 0.030). At a willingness-to-pay threshold of 20,000 and 30,000 euros, there was a 62.64% and 71.30% probability that RDP was more cost-effective than LDP, respectively. CONCLUSIONS: The RDP procedure in the Spanish healthcare system appears more cost-effective than the LDP.

Five-year recurrence/survival after pancreatoduodenectomy for pancreatic adenocarcinoma: does pre-existing diabetes matter? Results from the Recurrence After Whipple's (RAW) study.

BACKGROUND: Diabetes mellitus (DM) has a complex relationship with pancreatic cancer. This study examines the impact of preoperative DM, both recent-onset and pre-existing, on long-term outcomes following pancreatoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC). METHODS: Data were extracted from the Recurrence After Whipple's (RAW) study, a multi-centre cohort of PD for pancreatic head malignancy (2012-2015). Recurrence and five-year survival rates of patients with DM were compared to those without, and subgroup analysis performed to compare patients with recent-onset DM (less than one year) to patients with established DM. RESULTS: Out of 758 patients included, 187 (24.7%) had DM, of whom, 47 of the 187 (25.1%) had recent-onset DM. There was no difference in the rate of postoperative pancreatic fistula (DM: 5.9% vs no DM 9.8%; p = 0.11), five-year survival (DM: 24.1% vs no DM: 22.9%; p = 0.77) or five-year recurrence (DM: 71.7% vs no DM: 67.4%; p = 0.32). There was also no difference between patients with recent-onset DM and patients with established DM in postoperative outcomes, recurrence, or survival. CONCLUSION: We found no difference in five-year recurrence and survival between diabetic patients and those without diabetes. Patients with pre-existing DM should be evaluated for PD on a comparable basis to non-diabetic patients.

The role of clinically relevant intra-abdominal collections after pancreaticoduodenectomy : Clinical impact and predictors. A retrospective analysis from a European tertiary centre.

BACKGROUND: There is controversial evidence regarding the impact of clinically relevant postoperative intra-abdominal collections (CR-IC) on the clinical course after pancreaticoduodenectomy. C-reactive Protein (CRP) has been validated as a predictor of postoperative pancreatic fistula (POPF). Still, its role in predicting CR-IC has not been studied. METHODS: A retrospective analysis was conducted on patients who underwent PD at a tertiary hospital between October 2012 and October 2017. The incidence of CR-IC, clinically relevant POPF and other complications, as well as mortality and length of hospitalisation, was retrieved. The impact of CR-IR on mortality and major complications was analysed. The serum CRP levels were retrieved on the third and fifth postoperative days (POD3 and POD5), followed by an analysis of sensitivity, specificity, and area under the curve to predict CR-IC using CRP. RESULTS: One hundred forty patients were enrolled following inclusion and exclusion criteria. The mean age was 66.5 years (15-83). The incidence of CR-IC was 33.7% (47), and CR-POPF was 24.3%. Pancreatic duct diameter ≤ 4 mm was identified as a risk factor related to CR-IC occurrence. The group of patients who developed CR-IC after PD exhibited a higher rate of complications Clavien-Dindo ≥ III compared to patients without CR-IC (40.4% vs 7.5%, p < 0.001), as well as other events such as admission to the intensive care unit (25.5% vs 4.3%, p < 0.001), the incidence of CR-POPF (66% vs 3.2%, p < 0.001), prolonged hospital stay (32 vs 13 days, p < 0.001), postoperative haemorrhage (23.4 vs 5.4%, p = 0.002), and delayed gastric empty (38.8% vs 11.8%, p < 0.001) respectively. Logistic regression analysis identified CR-IC related to POPF as a risk factor for Clavien-Dindo > III: OR = 10.6 (95% CI: 3.90-28.7). No differences in mortality were reported between the CR-IC group and non-CR-IC group. CRP at postoperative day 3 (POD3) > 17.55 mg/dl and CRP at postoperative day 5 (POD5) > 13.46 mg/dl were predictors of CR-IC (AUC: 0.731 and AUC:0.821, respectively). CONCLUSIONS: CR-IC has a significant impact after pancreaticoduodenectomy and is associated with a higher incidence of Clavien-Dindo ≥ III complications. Additionally, CRP levels at POD3 and POD5 play a role in predicting CR-IC. Prospective studies are essential to explore strategies for mitigating the occurrence of CR-IC after PD.

Patterns, timing and predictors of recurrence following pancreaticoduodenectomy for distal cholangiocarcinoma: An international multicentre retrospective cohort study.

INTRODUCTION: Patients undergoing pancreaticoduodenectomy for distal cholangiocarcinoma (dCCA) often develop cancer recurrence. Establishing timing, patterns and risk factors for recurrence may help inform surveillance protocol strategies or select patients who could benefit from additional systemic or locoregional therapies. This multicentre retrospective cohort study aimed to determine timing, patterns, and predictive factors of recurrence following pancreaticoduodenectomy for dCCA. MATERIALS AND METHODS: Patients who underwent pancreaticoduodenectomy for dCCA between June 2012 and May 2015 with five years of follow-up were included. The primary outcome was recurrence pattern (none, local-only, distant-only or mixed local/distant). Data were collected on comorbidities, investigations, operation details, complications, histology, adjuvant and palliative therapies, recurrence-free and overall survival. Univariable tests and regression analyses investigated factors associated with recurrence. RESULTS: In the cohort of 198 patients, 129 (65%) developed recurrence: 30 (15%) developed local-only recurrence, 44 (22%) developed distant-only recurrence and 55 (28%) developed mixed pattern recurrence. The most common recurrence sites were local (49%), liver (24%) and lung (11%). 94% of patients who developed recurrence did so within three years of surgery. Predictors of recurrence on univariable analysis were cancer stage, R1 resection, lymph node metastases, perineural invasion, microvascular invasion and lymphatic invasion. Predictors of recurrence on multivariable analysis were female sex, venous resection, advancing histological stage and lymphatic invasion. CONCLUSION: Two thirds of patients have cancer recurrence following pancreaticoduodenectomy for dCCA, and most recur within three years of surgery. The commonest sites of recurrence are the pancreatic bed, liver and lung. Multiple histological features are associated with recurrence.

Minimally invasive robot-assisted and laparoscopic distal pancreatectomy in a pan-European registry a retrospective cohort study.

BACKGROUND: International guidelines recommend monitoring the use and outcome of minimally invasive pancreatic surgery (MIPS). However, data from prospective international audits on minimally invasive distal pancreatectomy (MIDP) are lacking. This study examined the use and outcome of robot-assisted (RDP) and laparoscopic (LDP) distal pancreatectomy in the E-MIPS registry. PATIENTS AND METHODS: Post-hoc analysis in a prospective audit on MIPS, including consecutive patients undergoing MIDP in 83 centers from 19 European countries (01-01-2019/31-12-2021). Primary outcomes included intraoperative events (grade 1: excessive blood loss, grade 2: conversion/change in operation, grade 3: intraoperative death), major morbidity, and in-hospital/30-day mortality. Multivariable logistic regression analyses identified high-risk groups for intraoperative events. RDP and LDP were compared in the total cohort and high-risk groups. RESULTS: Overall, 1672 patients undergoing MIDP were included; 606 (36.2%) RDP and 1066 (63.8%) LDP. The annual use of RDP increased from 30.5% to 42.6% ( P <0.001). RDP was associated with fewer grade 2 intraoperative events compared with LDP (9.6% vs. 16.8%, P <0.001), with longer operating time (238 vs. 201 min, P <0.001). No significant differences were observed between RDP and LDP regarding major morbidity (23.4% vs. 25.9%, P =0.264) and in-hospital/30-day mortality (0.3% vs. 0.8%, P =0.344). Three high-risk groups were identified; BMI greater than 25 kg/m 2 , previous abdominal surgery, and vascular involvement. In each group, RDP was associated with fewer conversions and longer operative times. CONCLUSION: This European registry-based study demonstrated favorable outcomes for MIDP, with mortality rates below 1%. LDP remains the predominant approach, whereas the use of RDP is increasing. RDP was associated with fewer conversions and longer operative time, including in high-risk subgroups. Future randomized trials should confirm these findings and assess cost differences.

Repeated pancreatic resection for pancreatic metastases from renal cell Carcinoma: A Spanish multicenter study (PANMEKID).

BACKGROUND AND OBJECTIVES: Recurrent isolated pancreatic metastasis from Renal Cell Carcinoma (RCC) after pancreatic resection is rare. The purpose of our study is to describe a series of cases of relapse of pancreatic metastasis from renal cancer in the pancreatic remnant and its surgical treatment with a repeated pancreatic resection, and to analyse the results of both overall and disease-free survival. METHODS: Multicenter retrospective study of patients undergoing pancreatic resection for RCC pancreatic metastases, from January 2010 to May 2020. Patients were grouped into two groups depending on whether they received a single pancreatic resection (SPS) or iterative pancreatic resection. Data on short and long-term outcome after pancreatic resection were collected. RESULTS: The study included 131 pancreatic resections performed in 116 patients. Thus, iterative pancreatic surgery (IPS) was performed in 15 patients. The mean length of time between the first pancreatic surgery and the second was 48.9 months (95 % CI: 22.2-56.9). There were no differences in the rate of postoperative complications. The DFS rates at 1, 3 and 5 years were 86 %, 78 % and 78 % vs 75 %, 50 % and 37 % in the IPS and SPS group respectively (p = 0.179). OS rates at 1, 3, 5 and 7 years were 100 %, 100 %, 100 % and 75 % in the IPS group vs 95 %, 85 %, 80 % and 68 % in the SPS group (p = 0.895). CONCLUSION: Repeated pancreatic resection in case of relapse of pancreatic metastasis of RCC in the pancreatic remnant is justified, since it achieves OS results similar to those obtained after the first resection.

¿Es realmente la afectación del ganglio de la arteria hepática un factor de mal pronóstico en el adenocarcinoma de páncreas? / Is the involvement of the hepatic artery lymph node a poor prognostic factor in pancreatic adenocarcinoma?

INTRODUCCIÓN: El objetivo del presente estudio es analizar el impacto de la afectación del ganglio de la arteria hepática (GAH) en la supervivencia de los pacientes intervenidos de duodenopancreatectomía cefálica (DPC) por adenocarcinoma (ADK) de cabeza de páncreas. MÉTODOS: Estudio retrospectivo unicéntrico de pacientes intervenidos de DPC por ADK de cabeza de páncreas, con estudio anatomopatológico independiente del GAH. Los pacientes se agruparon en: 1) pacientes sin afectación del GAH ni ganglios peripancreáticos (GGP) (GPP-/GAH-); 2) pacientes con afectación ganglionar peripancreática (GPP+/GAH-), y 3)pacientes con afectación ganglionar peripancreática y de la arteria hepática (GGP+/GAH+). Para el análisis de supervivencia se utilizaron las curvas Kaplan-Meier. Los factores pronósticos de supervivencia global (SG) y libre de enfermedad (SLE) fueron identificados mediante el análisis de regresión de Cox. RESULTADOS: Entre enero de 2005 y diciembre de 2014 se intervinieron 118 pacientes, y el GAH fue analizado en 64 de ellos. La mediana de seguimiento fue de 20 meses (r: 1-159 meses). La distribución por grupos fue la siguiente: GPP-/GAH- en 12 (19%), GPP+/GAH- en 40 (62%), GGP+/GAH+ en 12 (19%) y CGP-/CGH+ en 0 (0%), La SG a 1, 3 y 5años fue estadísticamente mejor en el grupo GPP-/GAH- (82, 72 y 54%) comparado con GPP+/GAH- (68, 29 y 21%) y GGP+/GAH+ (72, 9 y 9%) (p = 0,001 vs p = 0,007). La probabilidad acumulada de recidiva a 1, 3 y 5 años fue estadísticamente inferior en el grupo GPP-/GAH- (18, 46 y 55%) comparado con el grupo GPP+/GAH- (57, 80 y 89%) y grupo GGP+/GAH+ (46, 91 y 100%) (p = 0,006 vs p = 0,021). En el análisis multivariante el principal factor de riesgo tanto de SG como de SLE fue la invasión linfática independientemente del estado del GAH. CONCLUSIONES: Nuestros resultados sugieren que la afectación adenopática impacta en la supervivencia del ADK de páncreas sin poder identificar la afectación del GAH como marcador pronóstico

INTRODUCTION: The aim of this study is to analyze the impact of hepatic artery lymph node (HALN) involvement on the survival of patients undergoing pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma (PA). METHODS: A single-center retrospective study analyzing patients who underwent PD for PA. Patients were included if, during PD, the HALN was submitted for pathologic evaluation. Patients were stratified by node status: PPLN- (peripancreatic lymph node)/HALN-, PPLN+/HALN- and PPLN+/HALN+. Survival analysis was estimated by the Kaplan-Meier method, and Cox regression was used for risk factors analyses. RESULTS: Out of the 118 patients who underwent PD for PA, HALN status was analyzed in 64 patients. The median follow-up was 20months (r: 1-159months). HALN and PPLN were negative in 12 patients (PPLN-/HALN-, 19%), PPLN was positive and HALN negative in 40 patients (PPLN+/HALN-, 62%), PPLN and HALN were positive in 12 patients (PPLN+/HALN+, 19%) and PPLN was negative and HALN positive in 0 patients (PPLN-/HALN+, 0%). The overall 1, 3 and 5-year survival rates were statistically better in the PPLN-/HALN- group (82%, 72%, 54%) than in the PPLN+/HALN- group (68%, 29%, 21%) and the PPLN+/HALN+ group (72%, 9%, 9%, respectively) (P = .001 vs P = .007). The 1, 3 and 5-year probabilities of cumulative recurrence were also statistically better in the PPLN-/HALN- group (18%, 46%, 55%) than in the PPLN+/HALN- group (57%, 80%, 89%) and the PPLN+/HALN+ group (46%, 91%, 100%, respectively) (P = .006 vs P = .021). In the multivariate model, the main risk factor for overall survival and recurrence was lymphatic invasion, regardless of HALN status. CONCLUSIONS: In pancreatic adenocarcinoma patients with lymph node disease, survival after PD is comparable regardless of HALN status

Ampuloma en paciente con antecedente de bypass gastroyeyunal en Y de Roux / Ampulloma in a Patient with a History of Roux-en-Y Gastrojejunal Bypass

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¿Es la anastomosis pancreato yeyunal de Peng más efectiva que la anastomosis muco-mucosa en la duodenopancreatectomía por neoplasias de páncreas y periampulares? / Is Peng's pancreaticojejunal anastomosis more effective than mucosa-mucosa anastomosis in duodenopancreatectomy for pancreatic and peri-ampullary tumours?

Introducción La fístula pancreática es la complicación más temida luego de una duodenopancreatectomía, siendo el factor independiente de mortalidad postoperatoria más frecuente. Recientemente Peng et al. publicaron una técnica de anastomosis pancreato yeyunal «anastomosis por atadura» (binding anastomosis) que presentaba 0% de fístula pancreática. El objetivo de este estudio es evaluar y validar esta nueva técnica de anastomosis comparada con la anastomosis pancreato yeyunal termino-lateral ducto mucosa convencional (PYTL-C).Material y método Se efectuó un estudio prospectivo no aleatorizado para evaluar y validar esta nueva técnica de anastomosis comparada con la anastomosis pancreato yeyunal termino-lateral convencional. Se incluyó a 63 pacientes a quienes se les realizó una duodenopancreatectomía por presentar una neoplasia pancreática o periampular, intervenidos por un mismo cirujano. A 30 pacientes (Grupo A) se les realizó una anastomosis termino-terminal según la técnica descrita por Peng, y a 33 pacientes (Grupo B) se les realizó una anastomosis termino-lateral mucosa-mucosa (técnica convencional).Resultados Cuando se compararon las 2 técnicas, la fístula pancreática se presentó en 2/30 pacientes (6,6%) con anastomosis de Peng y en 4/33 pacientes (12%) con anastomosis mucosa-mucosa, sin embargo esto no fue significativo (p=0,674). Además cuando se comparó la morbilidad, estancia hospitalaria y mortalidad tampoco existió diferencia significativa entre los 2 grupos. Conclusión Los resultados de este estudio muestran que la anastomosis descrita por Peng es un método seguro, pero que no está asociada a una menor frecuencia de fístula pancreática, morbilidad general, ni mortalidad, por lo cual se puede poner en duda si realmente presenta una ventaja sobre otras técnicas (AU)

Introduction The pancreatic fistula is the most feared complication after a duodenopancreatectomy, and is the most common independent factor of post-surgical mortality. Peng et al. recently published a pancreaticojejunal anastomosis technique (binding anastomosis) which showed 0% pancreatic fistulas. The objective of this study is to evaluate and validate this new anastomosis technique compared with the conventional pancreaticoduodenectomy with end-to-side duct-to-mucosa anastomosis. Material and method A prospective, non-randomised study was conducted to evaluate and validate this new anastomosis technique compared with the conventional pancreaticojejunal terminolateral duct to mucosa anastomosis. The study included 63 patients who were subjected to a duodenopancreatectomy due to having a pancreatic or periampullary neoplasm. A binding pancreaticojejunostomy according to the technique described by Peng et al. was performed on 30 patients (Group A), and a pancreaticoduodenectomy with end-to-side duct-to-mucosa anastomosis (conventional technique) was performed on 33 patients (Group B).Results When the results of the 2 techniques were compared, 2/30 (6%) of patients had a pancreatic fistula with the Peng technique, and 4/33 (12%) with the conventional technique, but this was not statistically significant (P=.674). Nor were there any significant differences between the 2 groups on comparing, morbidity, hospital stay and mortality. Conclusion The results of this study show that the anastomosis method described by Peng is safe, but is not associated with a lower frequency of pancreatic fistula, general morbidity, or mortality. This leads to the uncertainty of whether it really has any advantages over other techniques (AU)

Evaluación de los factores condicionantes de morbi-mortalidad en la duodenopancreatectomía por neoplasias periampulares / Evaluation of conditioning factors or morbimortality in duodenopancreatectomy in periampullary neoplasms

El propósito de este estudio, es definir cuales son los factores que condicionan las complicaciones y la mortalidad en un grupo de 119 pacientes con neoplasias peri ampulares operados en un hospital general. MATERIAL Y MÉTODO: Desde Octubre del 2002 hasta Diciembre del 2006 se analizaron 119 pacientes operados de duodenopancreatectomía en el hospital Rebagliati por el diagnostico de neoplasia peri ampular.RESULTADOS: La edad y el sexo no fueron factores condicionantes de complicaciones. Se observo una diferencia significativa en el tipo de anastomosis pancreática utilizadadonde el telescopaje fue un factor condicionante de complicación (p<0.009) Cuando se comparó con a la anastomosis mucosa-mucosa. Al analizar el sangrado con cada una de las complicaciones, se pudo ver que existía una relación significativa entre el mayor volumen de sangrado en sala de operaciones con el desarrollo de fístula pancreática (p<0.03), reoperación (p<0.01), absceso (p<0.006), y fístula intestinal (p<0.001). Se evaluó cuales fueron las complicaciones relacionados a la mortalidad en los pacientes sometidos a Pancreatoduodenectomía (PD), se pudo observar que la fístula pancreática (p<0.003), la fístula intestinal (p<0.003), la fístula biliar (p<0.03), la hemorragia intra abdominal, el sangrado en Sala de Operaciones (SOP), las transfusiones y las reoperaciones fueron factores que aumentaron la mortalidad, en forma significativa. Cuando se evaluó al cirujano como factor de morbi-mortalidad, se pudo comprobar queexistía una relación entre el volumen quirúrgico y la incidencia de complicaciones y mortalidad. Teniendo una menor estancia hospitalaria una menor incidencia en el sangradointra operatorio y una morbi-mortalidad menor en el grupo de alto volumen quirúrgico. CONCLUSIONES: Las complicaciones más temidas ya que se relacionan directamente con la mortalidad son: la fístula intestinal, hemorragia intra abdominal, absceso intraabdominal, fístula biliar y la necesidad de...

OBJECTIVE: The purpose of this study is to define the factors that condition complications and mortality in a group of 119 patients with periampullary neoplasms operated on at a general hospital. MATERIALS & METHOD: Between October 2002 and December 2006, 119 patients who were diagnosed with periampullary neoplasms and underwent a pancreatoduodenectomyat Rebagliati Hospital were evaluated. RESULTS: Age and sex were not conditioning factors of complications. A significant difference in the type of pancreatic anastomosis used was noticed, whereby telescopingwas a conditioning factor of complication (p<0.009) compared with mucous-mucous anastomosis. After analyzing the bleeding associated with each complication, a significant connection was established between the greatest bleeding volume obtained in the operating room with the development of pancreatic fistulas (p<0.03), re-operation (p<0.01), abscesses (p<0.006) and intestinal fistulas (p<0.001). The complications related to mortality in patients who underwent a pancreatoduodenectomy (PD) were evaluated. It was observed that pancreatic fistulas (p<0.003), intestinal fistulas (p<0.003) and gallbladder fistulas (p<0.03), intra-abdominal hemorrhaging and bleeding during a standard operating procedure (SOP), transfusions and re-operations were factors that increased mortality significantly. When the surgeon was evaluated as a factor of morbimortality, it was proven that there was a connection between the surgical volume and the incidence of complications andmortality. There was a shorter hospital stay, a lower incidence of intra-operative bleeding and lower morbimortality in the high surgical volume group.CONCLUSIONS: The most-feared complications, since they are directly related to mortality, are intestinal fistulas, intra-abdominal hemorrhaging, intra-abdominal abscesses,gallbladder fistulas and the need to undergo repeated operations. Both complications and mortality are directly related to the...

Morbilidad y mortalidad postoperatorias de acuerdo al “factor cirujano” tras duodenopancreatectomía / Morbidity and mortality rates in relation to the "surgeon factor" after duodenopancreatectomy

Objetivos. El presente estudio está diseñado para determinar si hay un efecto independiente en la morbilidad y la mortalidad operatoria luego de la duodenopancreatectomía tomando en cuenta el factor cirujano. Material y método. Durante el período comprendido entre octubre de 2002 y diciembre de 2006 se realizó un estudio sobre 119 pacientes, a quienes se les realizó una duodenopancreatectomía. Se dividió a los cirujanos según el número de pacientes operados por año en 3 grupos, de bajo volumen (hasta 3 Whipple por año), mediano volumen (más de 3 hasta 10 Whipple por año) y alto volumen (> 10 Whipple por año). Resultados. La morbilidad fue mayor en el grupo de bajo volumen (82%) en comparación con el de alto volumen (35%). La estancia hospitalaria fue marcadamente mayor en los grupos de bajo y mediano volumen (27 días y 21 días) en comparación con el grupo de alto volumen en que fue de 17 días. Cuando se compararon los resultados de los 3 grupos, se evidenció que el grupo que tuvo 3 o menos cirugías por año (bajo volumen) presentó la tasa más alta de mortalidad (47%), mientras que el grupo de más de 10 cirugías por año (alto volumen) presentó una mortalidad muy baja (4%). Conclusiones. Encontramos que la relación volumen/ cirujano era inversamente proporcional a la morbilidad, estancia hospitalaria, reinicio de la vía oral y mortalidad. Por lo que podríamos suponer que el volumen quirúrgico podría mejorar la morbilidad y la mortalidad (AU)

Objectives. The present study was designed to determine whether the surgeon factor has an independent effect on morbidity and mortality rates after duodenopancreatectomy. Material and method. Between October 2002 and December 2006, we performed a study of 119 patients who underwent duodenopancreatectomy. The surgeons were divided into 3 groups according to the number of interventions they performed each year: a low volume group (three Whipple procedures per year), a medium volume group (four to 10 Whipple procedures per year) and a high volume group (> 10 Whipple procedures per year). Results. The morbidity rate was higher in the low volume group (82%) than in the high volume group (35%). Length of hospital stay was clearly longer in the low and medium volume groups (27 days, and 21 days) than in the high volume group (17 days). Comparison of the results of the 3 groups revealed that the group performing three or less interventions per year (low volume) had the highest mortality rate (47%), while the group performing more than 10 interventions per year (high volume) had a very low mortality rate (4%). Conclusions. We found that the volume-to-surgeon ratio was inversely proportional to morbidity, length of hospital stay, return to oral intake, and mortality rates. Therefore, increasing surgical volume could improve morbidity and mortality rates (AU)