Centralizing a national pancreatoduodenectomy service: striking the right balance.

BACKGROUND: Centralization of pancreatic surgery is currently called for owing to superior outcomes in higher-volume centres. Conversely, organizational and patient concerns speak for a moderation in centralization. Consensus on the optimal balance has not yet been reached. This observational study presents a volume-outcome analysis of a complete national cohort in a health system with long-standing centralization. METHODS: Data for all pancreatoduodenectomies in Norway in 2015 and 2016 were identified through a national quality registry and completed through electronic patient journals. Hospitals were dichotomized (high-volume (40 or more procedures/year) or medium-low-volume). RESULTS: Some 394 procedures were performed (201 in high-volume and 193 in medium-low-volume units). Major postoperative complications occurred in 125 patients (31·7 per cent). A clinically relevant postoperative pancreatic fistula occurred in 66 patients (16·8 per cent). Some 17 patients (4·3 per cent) died within 90 days, and the failure-to-rescue rate was 13·6 per cent (17 of 125 patients). In multivariable comparison with the high-volume centre, medium-low-volume units had similar overall complication rates, lower 90-day mortality (odds ratio 0·24, 95 per cent c.i. 0·07 to 0·82) and no tendency for a higher failure-to-rescue rate. CONCLUSION: Centralization beyond medium volume will probably not improve on 90-day mortality or failure-to-rescue rates after pancreatoduodenectomy.

ANTECEDENTES: Actualmente se aboga por la centralización de la cirugía pancreática debido a los mejores resultados obtenidos en los centros de mayor volumen. Por el contrario, la preocupación de las organizaciones y de los pacientes está en línea con la sobriedad en la centralización. Todavía no se ha alcanzado un consenso en el equilibrio óptimo. Este estudio observacional presenta un análisis de volumen-resultado de una cohorte nacional completa en un sistema de salud con largo tiempo de centralización. MÉTODOS: Se identificaron los datos de todas las duodenopancreatectomías realizadas en Noruega en 2015 y 2016 a través de un registro nacional de calidad y se completaron a través de los datos electrónicos de los pacientes. Los hospitales fueron dicotomizados (volumen alto (≥ 40 procedimientos/año) o volumen medio/bajo)) RESULTADOS: Se realizaron 394 procedimientos (201 versus 193 en unidades de volumen alto versus volumen medio/bajo). Un total de 125 pacientes (31,7%) presentaron complicaciones postoperatorias mayores. Se diagnosticó una fístula pancreática postoperatoria clínicamente relevante en 66 pacientes (16,8%). En total, 17 pacientes (4,3%) fallecieron dentro de los 90 días, y la tasa de fracaso de rescate fue de 17 de 125 (13,6%) pacientes. En el análisis multivariable de comparación con el centro de volumen alto, las unidades de volumen medio/bajo presentaron tasas de complicaciones generales iguales, menor mortalidad a los 90 días (razón de oportunidades, odds ratio, OR 0,2, i.c. del 95% 0,1-0,8) y sin tendencia a una mayor tasa de fracaso de rescate. CONCLUSIÓN: La centralización más allá del volumen medio probablemente no mejore la mortalidad a los 90 días o las tasas de fracaso de rescate después de la duodenopancreatectomía.

Impact of perioperative chemotherapy on oncological outcomes after gastric cancer surgery.

BACKGROUND: Perioperative chemotherapy has become standard care for resectable gastric cancer. However, available evidence is based on a limited number of trials, and the outcomes in routine clinical practice and in unselected patients are scarcely reported. METHODS: The study included a consecutive series of patients with resectable gastric cancer treated between 2001 and 2011 in Central Norway. Before 2007, patients with resectable gastric cancer did not receive perioperative chemotherapy. Since 2007, medically fit patients with resectable gastric cancer and aged 75 years or less have been offered this. Response rates were evaluated by CT, and tolerability was assessed by the frequency of hospital admission, need for dose reduction or treatment discontinuation. The two time intervals were compared on an intention-to-treat basis for patients aged no more than 75 years for any impact on resection rates, surgical morbidity, postoperative mortality and long-term survival. RESULTS: About two-thirds (259) of the 419 patients registered were aged 75 years or less at diagnosis. Ninety-five of 136 patients in the later interval were eligible for chemotherapy, of whom 90 actually received the specified regimen, and 78 (87 per cent) were able to complete the preoperative course. Only 40 (44 per cent) completed all scheduled preoperative and postoperative cycles. Thirty-eight (43 per cent) of 89 evaluable patients showed a definite response on CT. Chemotherapy had no impact on postoperative morbidity or mortality. The 5-year survival rate on an intention-to-treat basis was 40·7 (95 per cent c.i. 30·7 to 50·7) per cent in the first interval, compared with 41·7 (31·5 to 51·9) per cent after the introduction of perioperative chemotherapy (P = 0·765). After adjustment for other risk factors, based on comparisons of the two time intervals, there were no differences in oncological outcomes with the use of perioperative chemotherapy. CONCLUSION: Perioperative chemotherapy was completed in less than half of the patients with resectable gastric cancer. An observed tumour response to chemotherapy did not translate into any long-term survival benefit compared with surgery alone.

Outcomes among patients treated for gastric adenocarcinoma during the last decade.

OBJECTIVES: To evaluate the outcomes among patients treated for gastric adenocarcinoma in a referral hospital, and to identify possible trends during the last decade. METHODS: All patients evaluated for gastric adenocarcinoma during the period 1999-2009 were included. RESULTS: Of 397 patients, 52% were curatively resected. Crude 5-year survival for the first 6 years period was 38.7% (CI 29.5-47.9), for the last 5 years, 49.2% (CI 38.8-59.6). Time period (P = 0.013), age (P < 0.001) and disease stage (P < 0.001), were significant predictors of long-term survival rates. Among curatively resected, in-hospital mortality was reduced from 8.5% in the first period to 2.0% in the last one (P = 0.037). There was a significant increase in the use of primary stents from the first to the last period (P = 0.006), paralleled by a significant reduction in the number of explorative laparotomies or bypass procedures (P < 0.001). CONCLUSIONS: During the last decade, long-term survival rates improved among patients curatively resected for gastric adenocarcinoma, and in-hospital mortality was substantially reduced. For patients in a non-curative situation, there was a significant shift from explorative laparotomies or bypass procedures to primary use of stents.

[Reduced blood utilization in hip arthroplasty. Introduction of a blood preservation program]. / Reduksjon i blodforbruket ved hofteprotesekirurgi. Gjennomføring av et blodspareprogram.

In spring 1992 a blood conservation programme was established at Nordland Central Hospital with emphasis on indications for blood transfusion and intraoperative blood salvage (cell-saver). Medical records from all patients who underwent hip arthroplasty during the period 1 June 1991 to 28 February 1994 were examined. Mean transfusion of homologous SAGMAN-blood (bank blood) was substantially reduced during the period: for total prosthesis (n = 192) from 2.6 to 1.1 units per operation (p < 0.0001) and for hemiprosthesis (n = 66) from 3.1 to 0.9 units per operation (p = 0.0202). The percentage of patients in each of these two groups who did not receive blood transfusion at all increased from 18 to 61 in the first group (p < 0.0001) and from 24 to 65 (p = 0.0202) in the second. The substantial reduction of bank blood transfusion in this material conforms with current international transfusion guidelines. A particular benefit, considering the risk of transfusing contagious blood, is the marked increase in the number of patients who did not receive any blood product at all.