Hospital volume, margin status, and long-term survival after pancreaticoduodenectomy for pancreatic adenocarcinoma

An association between hospital surgical volume and short- and long-term outcomes after pancreatic surgery has been demonstrated. Identification of specific factors contributing to this relationship is difficult. In this study, the authors evaluated if margin status can be identified as a measure of surgical quality, affecting overall survival, as a function of hospital pancreaticoduodenectomy volume. A systematic review of the literature was performed. Two models for analysis were created, dividing the 18 studies identified into quartiles and two quantiles based on the average annual hospital pancreatectomy volume. Regression modeling and analysis of variance were used to find an association between hospital volume, margin status, and survival. Increasing hospital volume was associated with a significantly increased negative margin status rate: 55 per cent for low-volume, 72 per cent for medium-volume, 74.3 per cent for high-volume, and 75.7 per cent for very high-volume centers (P = 0.008). The negative margin status rates were 64 per cent and 75.1 per cent for volume centers with less and more than 12 pancreaticoduodenectomies/year, respectively (P = 0.04). Low-volume centers negatively affected both margin positive resection and 5-year survival rates, compared with high-volume centers. Margin status rate after pancreaticoduodenectomy could, therefore, be considered a measure of quality for selection of hospitals dedicated to pancreatic surgery.     

Relationship between hospital volume and late survival after pancreaticoduodenectomy.

BACKGROUND: Several studies have reported lower perioperative mortality rates with pancreaticoduodenectomy at high-volume hospitals than at low-volume hospitals. We sought to determine whether volume is also related to survival after hospital discharge. METHODS: Using information from the Medicare claims database, we performed a retrospective cohort study of all 7229 patients over age 65 undergoing pancreaticoduodenectomy in the United States between 1992 and 1995. We divided the study population into approximate quartiles according to their hospital's average annual volume of pancreaticoduodenectomies in Medicare patients: very low (< 1/y), low (1-2/y, medium (2-5/y), and high (5+/y). To adjust for potentially confounding variables, we used a Cox proportional hazards model to examine relationships between hospital volume and mortality, our primary outcome measure. RESULTS: Overall, 3-year survival was higher at high-volume centers (37%) than at medium- (29%), low- (26%), and very low volume hospitals (25%) (log-rank P < .0001). After excluding perioperative deaths and adjusting for case-mix, patients undergoing surgery at high-volume hospitals remained less likely to experience late mortality than patients at very low volume centers (adjusted hazard ratio 0.69, 95% CI 0.62-0.76). Relationships between hospital volume and survival after discharge were not restricted to patients with cancer diagnoses; patients with benign disease had similar improvements in late survival after surgery at high-volume centers. CONCLUSIONS: Hospital volume strongly influences both perioperative risk and long-term survival after pancreaticoduodenectomy. Our data suggest that both patient selection and differences in quality of care may underlie better outcomes at high-volume referral centers.     

Improving Results of Pancreaticoduodenectomy for Pancreatic Cancer

This report from The Johns Hopkins Hospital reviews the results of pancreaticoduodenal resection during the decade of the 1990s, focusing on two recent publications. The first to be discussed involves a cohort of 650 consecutive patients undergoing pancreaticoduodenectomy (PD), with 443 patients having periampullary adenocarcinomas, 282 of whom had a pathologic diagnosis of pancreatic adenocarcinoma. The second report to be discussed involves the use of adjuvant chemoradiation therapy in a cohort of 174 patients who had successfully undergone PD for pancreatic adenocarcinoma. In both of these cohorts the operative mortality was less than 2%, and the median survival for resected pancreatic adenocarcinoma approximated 20 months.     

Surgical workload and outcome after resection for carcinoma of the oesophagus and cardia

BACKGROUND: Performing cancer surgery in high-volume centres may lead to improved outcomes. This study explored the relationship between annual workload and outcome following resection for carcinoma of the oesophagus and cardia. METHODS: The study was a retrospective case-note review of 1125 patients who had surgery for cardio-oesophageal cancer in the West Midlands region of England. Outcome measures were 30-day mortality and long-term survival. RESULTS: The overall 30-day mortality rate was 10.0 per cent with a median survival of 14 months and a 5-year survival rate of 17.2 per cent. Increasing age, advanced stage of disease and emergency resection independently affected outcome adversely. Forty-one infrequent operators (fewer than four resections per year) performed 146 resections (13.0 per cent), 18 intermediate operators (between four and 11 resections per year) performed 488 resections (43.4 per cent) and five frequent operators (12 or more resections per year) performed 491 resections (43.6 per cent). The 30-day mortality rate was greatest in the infrequent group (15.1 per cent) compared with both the intermediate group (6.6 per cent; adjusted odds 0.40, P = 0.004) and the frequent group (11.8 per cent; odds 0.73, P = 0.28). There were no differences in survival rates between the groups, and no difference in outcome between high- and low-volume hospitals. CONCLUSION: In this unselected population-based series there was little evidence of a trend of improving 30-day mortality rate with increasing workload, or between workload and long-term survival.     

Esophageal carcinoma. Improved quality of survival with resection

Twenty years ago the experience with carcinoma of the esophagus at Vanderbilt University and affiliated hospitals was reported in 263 patients. Overall 5-year survival was 2 per cent. Esophagectomy was possible in 89 patients (34%) and was associated with a 32 per cent mortality. This study updates the authors' experience with squamous cell carcinoma of the esophagus in 311 patients seen from 1966 to 1985. Overall 5-year survival has increased to 6 per cent. Esophageal resection was accomplished in 104 patients (33%), with a 10 per cent operative mortality and 41 per cent complication rate. Multi-variant analysis disclosed that smoking, alcohol use, sex, race, and site of tumor did not influence survival. Actuarial survival rates following esophageal resection were 51 per cent at 1 year, 21 per cent at 2 years, and 13 per cent at 5 years. These survival rates were not influenced by adjuvant radiotherapy. Radiation therapy was used for attempted cure in 83 patients. Actuarial survival rates following curative doses of radiation were 29 per cent at 1 year, 15 per cent at 2 years, and 4 per cent at 5 years. These survival rates were significantly (P less than 0.001) lower than survival rates following esophagectomy. The quality of life following treatment was good or fair in 83 per cent of patients undergoing esophagectomy and good or fair in 64 per cent of patients receiving "curative" doses of radiation. The results of this review demonstrate that esophageal resection using the Lewis operation or transhiatal esophagectomy can be done with an acceptable operative mortality, results in prolonged survival, and improves the quality of life.     

Isolated replacement of the mitral valve with the Starr-Edwards prosthesis.

Isolated mitral valve replacement with the Starr-Edwards prosthesis has been performed on 657 patients at the Mayo Clinic during the 11 year period ending January, 1972. The most recent subset of that series comprised patients who received the Model 6120 prosthesis. In this group, the operative mortality rate was 9 per cent and the actuarial late death rate at 5 years was 20 per cent. This survival rate is a significant improvement over the natural history of severe mitral valve disease. Factors associated with operative deaths are large left artrial size, advanced functional class, and previous heart surgery. Variables associated with higher incidence of late deaths are large left atrial size, patient age at operation, and multivalve disease. Risk of thromboembolism is increased with large left atrial size, presence of left atrial thrombus, and inadequate anticoagulant therapy.     

Adjuvant concurrent chemoradiation for node-positive adenocarcinoma of the duodenum

HYPOTHESIS: Adjuvant chemoradiation improves local control and survival in patients with node-positive duodenal adenocarcinoma treated with pancreaticoduodenectomy. DESIGN: A retrospective review of outcomes, with a planned comparison with historical controls. SETTING: A single, high-volume academic referral center. PATIENTS: All patients with periampullary carcinoma treated with pancreaticoduodenectomy and adjuvant chemoradiotherapy at The Johns Hopkins Hospital between 1994 and 2003. Fourteen cases of node-positive duodenal adenocarcinoma were identified. Median radiation dose was 5000 cGy (range, 4000-5760 cGy). Concurrent fluorouracil-based chemotherapy was given with radiation therapy, followed by maintenance chemotherapy. RESULTS: The median follow-up was 12 months for patients who died and 42 months for those who lived. Death occurred in 7 of 14 patients (50%) during the follow-up period. Median survival for all patients was 41 months, and the 5-year survival rate was 44%. Of the 7 patients who experienced disease recurrence, 6 experienced distant metastasis as first recurrence. One of these 7 patients experienced both local recurrence and distant metastasis. Local control for all patients in the study was 93%, which compares favorably with local control reported in a series of patients treated with surgery alone (67%). Compared with historical controls treated with surgery alone, patients who received adjuvant chemoradiation therapy had an improved median survival (21 months vs 41 months, respectively). Overall 5-year survival, however, was not improved (44% vs 43%, respectively). CONCLUSION: Adjuvant chemoradiation therapy after pancreaticoduodenectomy for node-positive duodenal adenocarcinoma may improve local control and median survival but does not impact 5-year overall survival.     

Complications of carotid endarterectomy. A military hospital experience

The Naval Hospital Oakland (NHO) carotid study is a review of the morbidity and mortality of an 8-year experience of 201 consecutive carotid endarterectomies (164 patients). Arteriographic findings, risk factors, method of patient management, and all major and minor complications are discussed. Patient groups are categorized by indication for surgery and by the Mayo Clinic classification of Sundt. A credentialed attending surgeon assisted a senior general surgery resident (81.6%) or performed the operation himself (18.4%). Resident and staff adverse occurrences are compared. Complications in the NHO study were present in 35.8 per cent of cases (8.9% major). Elimination of myocardial infarction and transient ischemic attacks reduced this to 4 per cent. The experience is compared to one in a university setting, a Veteran Administration study, community hospital studies, and a study performed in another major military medical center.     

Extensive surgery for carcinoma of the gallbladder

BACKGROUND: The purpose of this study was to clarify the efficacy of, and define the indications for, extensive surgery for gallbladder carcinoma. METHODS: Between 1979 and 1994, 116 patients with gallbladder carcinoma underwent operation. Radical resection was performed in 80 patients. RESULTS: In 68 patients with stage III or IV disease, extensive resection including extended right hepatectomy (n = 40), pancreaticoduodenectomy (n = 23) and/or portal vein resection (n = 23) was employed to achieve complete tumour excision. The hospital mortality rate was 18 per cent. The postoperative 3- and 5-year survival rates were 44 and 33 per cent respectively in the patients with stage III disease (n = 9), and 24 and 17 per cent respectively in patients with stage IV (M0) disease (n = 29). In contrast, the postoperative survival rate for the 30 patients with stage IV (M1) disease (7 per cent at 3 years and 3 per cent at 5 years) was worse than that for patients with stage III and stage IV (M0) disease (P = 0.009 and P = 0.062 respectively). CONCLUSION: Radical resection should be undertaken for stage III and stage IV (M0) gallbladder cancer. Although portal vein resection and/or pancreaticoduodenectomy did not contribute to long-term survival, better survival was obtained than that for the unresected patients.     

Iliofemoral versus femorofemoral bypass: a 6-year audit.

Iliofemoral and femorofemoral crossover bypass operations performed over a 6-year period were reviewed. A total of 226 patients underwent 231 operations from 1984 to 1990. Seventy-two patients had 75 iliofemoral grafts and 154 patients had 156 femorofemoral grafts. The early mortality rate was 6 per cent for the iliofemoral group and 1.3 per cent for femorofemoral reconstruction. There was a higher reoperation rate in the iliofemoral group (31 versus 16.0 per cent). The cumulative patency rate at 6 years was 75 per cent for iliofemoral bypass and 92 per cent for the femorofemoral procedure (P < 0.01), while the survival rates for the same period were 55 and 74 per cent respectively (P < 0.01). Hospital stay was significantly shorter for patients undergoing femorofemoral bypass (P < 0.05).     

Adenocarcinoma of the ampulla of Vater. A 28-year experience.

OBJECTIVE: The aim of this study were to review the experience with adenocarcinoma of the ampulla of Vater at The Johns Hopkins Hospital and to determine what factors influenced the long-term outcome in these patients. SUMMARY BACKGROUND DATA: Adenocarcinoma of the ampulla of Vater is the second most common periampullary malignancy. However, most series have relatively small numbers. As a result, analysis of factors influencing outcome has been limited. METHODS: From 1969 to 1996, 120 patients with adenocarcinoma of the ampulla of Vater were managed at The Johns Hopkins Hospital. Clinical, operative, and pathologic factors were correlated with morbidity and long-term survival. Factors influencing outcome were evaluated by univariate and multivariate analyses. RESULTS: Resection was performed in 106 patients (88%), and 105 of these patients (99%) underwent either pancreatoduodenal resection (n = 103) or total pancreatectomy (n = 2). Resection rate increased from 62% in the 1970s to 82% in the 1980s to 96% in the 1990s (p < 0.05). Overall mortality after resection was 3.8% with no mortality in the 45 consecutive patients resected in the past 5 years. Morbidity also decreased significantly (p < 0.05) from 70% before to 38% after December 1992. Five-year survival for resected patient was 38%. Factors favorably influencing long-term outcome were resection (p < 0.001), no perioperative blood transfusions (p < 0.05), negative lymph node status (p = 0.05), and moderate or well-differentiated tumors (p < 0.05). In a multivariate analysis, the best predictor of prolonged survival was absence of intraoperative transfusion (p = 0.06, relative risk = 1.90, 95% confidence limits = 0.95-3.78). CONCLUSIONS: Compared to carcinoma of the pancreas, carcinoma of the ampulla of Vater has a higher resectability rate and a better prognosis. Early diagnosis is important because lymph node status influences survival. Careful operative dissection and avoidance of transfusions also improves long-term survival.     

Colorectal carcinoma at the Lahey Clinic, 1962-1966

A study of carcinoma of the colon and rectum carried out in 513 patients between 1962 and 1966 at the Lahey Clinic revealed an operability rate of 98 per cent. The rate of resection was 94 per cent, and the operative mortality was 4.5 per cent. The uncorrected five year survival rate for those undergoing surgery for cure was 62 per cent. The uncorrected survival rate for Dukes' lesions A, B, and C was 84, 65, and 36 per cent, respectively; the corrected survival rates were 98, 79, and 42 per cent, respectively. Decreased survival is noted with increased nodal involvement and with the presence of blood vessel invasion. A possible change in the metastatic potential of colorectal carcinoma is postulated.     

Community mortality after ruptured abdominal aortic aneurysm is unrelated to the distance from the surgical centre

BACKGROUND: Ruptured abdominal aortic aneurysm (RAAA) carries a high community mortality. Raigmore Hospital, Inverness serves Highland Region, an area the size of Wales with a population of 204,000. The aim of this retrospective review was to determine the community mortality and hospital mortality rates from RAAA in Highland Region and to assess whether distance travelled had any significant impact on survival. METHODS: Data were retrieved from hospital records, the Registrar General for Scotland and the Information and Statistics Division of the National Health Service in Scotland about patients diagnosed with RAAA between 1992 and 1999. RESULTS: Of 198 patients with RAAA, 131 (66 per cent) were transferred to Raigmore Hospital while the other 67 (34 per cent) died in a community hospital or at home. Of those reaching Raigmore 109 (83 per cent) had surgery, of whom 65 (60 per cent) survived. The overall community mortality rate was 67 per cent while the hospital mortality rate was 50 per cent. The hospital and community mortality rates for patients living within 50 miles of Raigmore Hospital were 60 and 67 per cent respectively, compared with 26 and 68 per cent for those living more than 50 miles away. CONCLUSION: Distance from Raigmore Hospital had no significant impact on community mortality from RAAA.     

Pancreaticoduodenectomy for cancer of the head of the pancreas. 201 patients.

OBJECTIVE: This single-institution study examined the outcome after pancreaticoduodenectomy in patients with adenocarcinoma of the head of the pancreas. SUMMARY OF BACKGROUND DATA: In recent years, pancreaticoduodenectomy for adenocarcinoma of the head of the pancreas has been associated with decreased morbidity and mortality and, in some centers, 5-year survival rates in excess of 20%. METHODS: Two hundred one patients with pathologically verified adenocarcinoma of the head of the pancreas undergoing pancreaticoduodenectomy at The Johns Hopkins Hospital between 1970 and 1994 were analyzed (the last 100 resections were performed between March 1991 and April 1994). This is the largest single-institution experience reported to date. RESULTS: The overall postoperative in-hospital mortality rate was 5%, but has been 0.7% for the last 149 patients. The actuarial 5-year survival for all 201 patients was 21%, with a median survival of 15.5 months. There were 11 5-year survivors. Patients resected with negative margins (curative resections: n = 143) had an actuarial 5-year survival rate of 26%, with a median survival of 18 months, whereas those with positive margins (palliative resections; n = 58) fared significantly worse, with an actuarial 5-year survival rate of 8% and a median survival of 10 months (p < 0.0001). Survival has improved significantly from decade to decade (p < 0.002), with the 3-year actuarial survival of 14% in the 1970s, 21% in the 1980s, and 36% in the 1990s. Factors significantly favoring long-term survival by univariate analyses included tumor diameter < 3 cm, negative nodal status, diploid tumor DNA content, tumor S phase fraction < 18%, pylorus-preserving resection, < 800 mL intraoperative blood loss, < 2 units of blood transfused, negative resection margins, and use of postoperative adjuvant chemotherapy and radiation therapy. Multivariate analyses indicated the strongest predictors of long-term survival were diploid tumor DNA content, tumor diameter < 3 cm, negative nodal status, negative resection margins, and decade of resection. CONCLUSIONS: The survival of patients with pancreatic adenocarcinoma treated by pancreaticoduodenectomy is improving. Aspects of tumor biology, such as DNA content, tumor diameter, nodal status and margin status, are the strongest predictors of outcome.     

Should esophagectomy be performed in a low-volume center?

A significant difference has been reported between rates of morbidity and mortality for elective esophagectomy performed at low-volume centers versus high-volume centers. Some authors have suggested that complex surgical procedures such as esophagectomy should be performed only in regional centers by surgeons with an extensive procedure-specific experience. This study was performed to review recent (5 years) experience with esophagectomy in two university-affiliated hospitals where a limited number of esophageal resections are performed annually. Esophageal resections performed between February 1995 and February 2000 at two university-affiliated tertiary-care hospitals were analyzed for operative morbidity and mortality. Variables reviewed included demographics, surgeon experience, mortality, and complications. Forty-three patients underwent elective esophagectomy during the 5-year study period. In-hospital mortality was 7.0 per cent and 30-day mortality was 4.7 per cent. The anastomotic leak rate was 11.6 per cent. No patients developed myocardial infarction or renal failure. Morbidity and mortality rates from our low-volume centers compared favorably with high-volume centers. We conclude that elective esophagectomy can be safely performed at low-volume centers with favorable morbidity and mortality rates. Recommendations urging regionalization of high-risk procedures should be guided by local outcomes and not by the total number of procedures performed at a specific center.     

Celestin tube palliation of unresectable esophageal carcinoma.

Celestin tube intubation was performed in 108 patients with unresectable carcinoma of the esophagus and cardia, in 83 per cent as the initial operation and in 17 per cent after exploration. The hospital mortality rate was 16 per cent, including a 7.4 per cent mortality rate from technical causes. The most frequent causes of death were perforations of the esophagus and cardia and aspiration pneumonia. Nonfatal complications occurred in 13 per cent of surviving patients, obstruction and dislodgment of the tube being the most common. All patients were able to swallow at discharge, and 91 per cent of them could take food by mouth until the time of death. In 9 per cent, additional palliation, usually esophagoscopy or gastrostomy, was required. Ninety-one patients survived one to 21 months (average 5.8 months). The 6 month survival rate was 44 per cent and the one-year survival 9 per cent.     

Severe trauma caused by stabbing and firearms in metropolitan Sydney, New South Wales, Australia

BACKGROUND: Stabbing and firearm trauma causing severe injuries (injury severity score (ISS) >15) and death is uncommon in Australia. The present study describes the experience with stabbings and firearm trauma causing severe injuries at a major Australian urban trauma centre. METHODS: Data from a prospectively generated trauma registry regarding all patients presenting to Royal Prince Alfred Hospital (RPAH), Sydney, Australia with penetrating trauma causing severe injuries from July 1991 to June 2001 was retrospectively analysed. RESULTS: Of all patients presenting to RPAH with stabbing and firearms wounds over the 11 year study period, 28% received an ISS >15. One hundred and forty patients were identified. 94% were male. The mean age was 34 years (15-82 years). The number of cases/year has not shown an increasing trend. Thirty per cent of patients sustained firearm related injuries, with the remainder mainly caused by knives or machetes. Fifteen per cent of injuries were self inflicted. The most common location of injury was on a public street. Fifty-two per cent of patients were injured in more than one anatomical region, with the abdomen being the most common site of injury (53%). On hundred and seventy-four operations were performed - laparotomies (43%), thoracotomies (26%), craniotomies (5%) and orthopaedic, vascular, wound explorations and other procedures (26%). Twenty-eight per cent of patients suffered at least one complication during their admission, with coagulopathy being the most common complication (20%). Mean length of stay was 10.4 days (1-107 days). The total mortality rate for the severely injured patients was 21%, with gun-related injuries having a higher mortality rate than stabbing injury (36%vs 15%). Sixty per cent of deaths were related to exsanguination. CONCLUSIONS: Stabbings and firearm trauma are associated with significant morbidity, mortality and utilization of hospital resources in metropolitan Sydney. Overall mortality rates are similar to institutions with higher volumes of penetrating trauma.     

Revision total hip arthroplasty

Two hundred and ten hips in 206 patients who had an initial total hip arthroplasty performed at the Mayo Clinic between 1969 and 1978 required revision of the arthroplasty at the Mayo Clinic for reasons other than infection. One hundred and sixty-two of the patients (166 hips) were followed both clinically and roentgenographically for two years or more. One hundred and forty-five (90 per cent) reported that they had improvement after the surgical revision. Complications that occurred with revision included deep sepsis, superficial would infection, dislocation, intraoperative femoral fracture, and postoperative femoral fracture. Roentgenographic analysis showed probable loosening in thirty-three acetabular components (20.1 per cent) and seventy-two femoral components (44 per cent). Symptomatic loosening (moderate to severe pain and probable roentgenographic loosening) was seen in thirty-five patients. Eight patients required a second revision for this reason, and seven others required a second revision for other reasons. Modified Harris hip scores, calculated for 108 hips, showed a good or excellent result in sixty-seven hips (62 per cent), a fair result in twelve (11 per cent), and a poor result in twenty-nine (27 per cent). Using a new Mayo Clinic hip score that incorporates roentgenographic data (which will be described) in the evaluation of 165 revised hips, there was a good or excellent result in eighty-five (52 per cent), a fair result in thirty-two (19 per cent), and a poor result in forty-eight hips (29 per cent). Although 90 per cent of the patients thought that their condition had improved, the high incidence of roentgenographic signs of probable loosening of a component is of serious concern.     

Harvey Cushing's Treatment of Skull Base Infections: The Johns Hopkins Experience

Objectives In this report, we review Dr. Cushing''s early surgical cases at the Johns Hopkins Hospital, revealing details of his early operative approaches to infections of the skull base.Design Following institutional review board (IRB) approval, and through the courtesy of the Alan Mason Chesney Archives, we reviewed the Johns Hopkins Hospital surgical files from 1896 to 1912.Setting The Johns Hopkins Hospital, 1896 to 1912.Participants Eleven patients underwent operative treatment for suspected infections of the skull base.Main Outcome Measures The main outcome measure was operative approach, postoperative mortality, and condition recorded at the time of discharge.Results Eleven patients underwent operative intervention for infections of the skull base. The mean age was 30 years (range: 9 to 63). Of these patients, seven (64%) were female. The mean length of stay was 16.5 days (range: 4 to 34). Postoperatively eight patients were discharged in “well” or “good” condition, one patient remained “unimproved,” and two patients died during their admission.Conclusion Cushing''s careful preoperative observation of patients, meticulous operative technique, and judicious use of postoperative drainage catheters contributed to a remarkably low mortality rate in his series of skull base infections.     

Pancreaticoduodenectomy in a community general surgery residency program

The morbidity and mortality of pancreaticoduodenectomy (PD) has been well documented. A retrospective review was performed to determine the morbidity and mortality of PD performed within the general surgery residency program of a tertiary community hospital. Patients undergoing PD for benign or malignant disease over a 6-year period were analyzed to determine overall mortality, major complication rate, and length of stay (LOS). Of 50 consecutive patients undergoing PD, overall mortality was 6 per cent, with a major complication rate of 52 per cent. Mean operative time was 333 +/- 68 minutes with an estimated blood loss of 459 +/- 301 mL. Mean hospital LOS was 21 +/- 13 days. Eighty-four per cent of patients with malignant disease had negative margins of resection. General surgery residents within a community residency program, with attending faculty supervision, can perform PD with mortality, morbidity, and LOS comparable with that reported in the university setting.