Whipple's procedure for pancreatic cancer: training and the hospital environment are more important than volume alone

Abstract

Patients diagnosed with pancreatic cancer in our center traditionally had Whipple's resections by General Surgery teams until January 2013 when a hepatopancreatobiliary (HPB) was introduced. We compared outcomes for Whipple's before and after introduction of HPB teams. Data were collected from the records of all patients booked for Whipple's resections over a 12-year period. The data were divided into two groups: Group A consisted of the 6-year period from January 1, 2007 to December 30, 2012 during which all resections were performed by General Surgery teams. Group B consisted of patients in the 6-year period from January 1, 2013 to December 30, 2019 during which operations were performed by HPB teams. All statistical analyses were carried out using SPSS ver 16.0 and a P Value <0.05 was considered statistically significant. The patients selected for Whipple's resections in Group A had statistically better performance status and lower anaesthetic risk. Despite this, patients in Group A had higher conversions to palliative operations (66% vs 5.3%), longer mean operating time (517.5±25 vs 367±54.1; P<0.0001), higher blood loss (3687.5±661.44 vs 1394±656.8; P<0.0001), greater transfusion requirements (4.25±1.26 vs 1.88±1.43; P=0.000894), greater likelihood of prolonged ICU stay (100% vs 40%; P=0.1878), higher overall morbidity (75% vs 22.2%; P=0.018), higher major morbidity (75% vs 13.9%; P=0.0132), more procedure-related complications (75% vs 9.7%; P0.0027) and higher mortality rates (75% vs 5.6%; P>0.0001). The HPB teams were more likely to perform vein resection and reconstruction to achieve clear margins (26.4% vs 0; P=0.5667). This paper adds to the growing body of evidence that volume alone should not be used as a marker of quality for patients requiring Whipple's procedures. Despite low volumes at our facility, we demonstrated that all metrics improved when specialty teams were introduced, hospital-based protocols were developed and continuous adaptive learning by the entire hospital were observed. In our center, patients with pancreatic cancer traditionally had Whipple's resections by general surgery teams until January 2013 when a hepatopancreatobiliary (HPB) was introduced. We compared outcomes before and after introduction of HPB teams. Data were collected from the records of all patients booked for Whipple's resections over a 12-year period. The data were divided into two groups: Group A consisted of the 6-year period from January 1, 2007 to December 30, 2012 during which all resections were performed by GS teams. Group B comprised patients in the 6-year period from January 1, 2013 to December 30, 2019 during which operations were performed by HPB teams. All statistical analyses were carried out using SPSS ver 16.0 and a P Value <0.05 was considered statistically significant. The patients selected for Whipple's resections in Group A had statistically better performance status and lower anaesthetic risk. Despite this, patients in Group A had higher conversions to palliative operations (66% vs 5.3%), longer mean operating time (517.5±25 vs 367±54.1; P<0.0001), higher blood loss (3687.5±661.44 vs 1394±656.8; P<0.0001), greater transfusion requirements (4.25±1.26 vs 1.88±1.43; P=0.000894), greater likelihood of prolonged ICU stay (100% vs 40%; P=0.1878), higher overall morbidity (75% vs 22.2%; P=0.018), higher major morbidity (75% vs 13.9%; P=0.0132), more procedure-related complications (75% vs 9.7%; P0.0027) and higher mortality rates (75% vs 5.6%; P>0.0001). The HPB teams were more likely to perform vein resection and reconstruction to achieve clear margins (26.4% vs 0; P=0.5667). This paper adds to the growing body of evidence that volume alone should not be used as a marker of quality for patients requiring Whipple's procedures.

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