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.

Short-term outcomes after elective colon cancer surgery: an observational study from the Norwegian registry for gastrointestinal and HPB surgery, NoRGast.

BACKGROUND: To describe the real burden of major complications after elective surgery for colon cancer in Norway, and to assess which predictors that are significantly associated with the short-term outcome. METHODS: An observational, multi-centre analysis of prospectively registered colon resections registered into the Norwegian Registry for Gastrointestinal Surgery, NoRGast, between January 2014 and December 2016. A propensity score-adjusted subgroup analysis for surgical access groups was attempted, with laparoscopic resections grouped as intention-to-treat. RESULTS: Out of 1812 resections, 14.0% of patients experienced a major complication within 30 days following surgery. The over-all reoperation rate was 8.7%, and rate of reoperation for anastomotic leak was 3.8%. Twenty patients (1.1%) died within 30 days after surgery. Higher age was not a significant predictor of major complications, including 30-day mortality. After correction for all co-variables, open access surgery was associated with higher rates of major complications (OR 1.67 (CI 1.22-2.29), p = 0.002), higher 30-day mortality (OR 4.39 (CI 1.19-16.13) p = 0.026) and longer length-of-stay (HR 0.58 (CI 0.52-0.65) p < 0.001). CONCLUSIONS: Our results indicate a low complication burden and high rate of uneventful patient journeys after elective surgery for colon cancer in Norway. Age was not associated with higher morbidity or mortality rates. Open access surgery was associated with an inferior short-term outcome.

Benchmarking of aggregated length of stay after open and laparoscopic surgery for cancers of the digestive system.

BACKGROUND: Length of hospital stay (LOS) may serve as a surrogate measure of healthcare quality and resource use, particularly when transfers of care and readmissions are accounted for. This study aimed to benchmark true hospital stay by measuring index, transfer and readmission stays across the range of digestive cancer surgery. METHODS: A cohort study of all patients undergoing resection for cancer of the oesophagus, stomach, liver, pancreas, colon or rectum in 2012-2016 was undertaken. Index LOS, transfer and readmission stays were merged into an 'aggregated' length of stay (a-LOS), and compared between organ sites and between open and minimal-access approaches. RESULTS: In total, 24 354 resections were reported (mean age of patients 68·3 years; 51·3 per cent were men). Resections were reported as laparoscopic for 9151 procedures (37·6 per cent), with a further 283 (3·0 per cent) described as converted to open surgery. Use of a-LOS compared with standard LOS added a median of 5 days for pancreatoduodenectomy, 4 days for major liver resections, 3 days for oesophageal and gastric resections, and 2 days for minor liver, distal pancreatic and rectal resections. CONCLUSION: Overall hospital stay across organ sites and procedures is better described by a-LOS. The study benchmarks the use of total hospital days during the first 30 days in a universal healthcare system.

The New National Registry for Gastrointestinal Surgery in Norway: NoRGast.

BACKGROUND AND AIMS: There is an increasing demand for high-quality data for the outcome of health care. Diseases of the gastro-intestinal tract involve large patient groups often presenting with serious or life-threatening conditions. Complications may affect treatment outcomes and lead to increased mortality or reduced quality of life. A continuous, risk-adjusted monitoring of major complications is important to improve the quality of health care to patients undergoing gastrointestinal resections. We present the development of the Norwegian Registry for Gastrointestinal Surgery, a national registry for colorectal, upper gastrointestinal, and hepato-pancreato-biliary resections in Norway. MATERIALS AND METHODS: A narrative and qualitative presentation of the development and current state of the registry. RESULTS: We present the variables and the analysis tools and provide examples for the potential in quality improvement and research. Core characteristics include a strictly limited set of variables to reflect important risk factors, the procedure performed, and the clinical outcomes. CONCLUSION: A registry with the potential to present complete national cohort data is a powerful tool for quality improvement and research.