Modelling centralization of pancreatic surgery in a nationwide analysis.

BACKGROUND: The benefits of centralization of pancreatic surgery have been documented, but policy differs between countries. This study aimed to model various centralization criteria for their effect on a nationwide cohort. METHODS: Data on all pancreatic resections performed between 2014 and 2016 were obtained from the Italian Ministry of Health. Mortality was assessed for different hospital volume categories and for each individual facility. Observed mortality and risk-standardized mortality rate (RSMR) were calculated. Various models of centralization were tested by applying volume criteria alone or in combination with mortality thresholds. RESULTS: A total of 395 hospitals performed 12 662 resections; 305 hospitals were in the very low-volume category (mean 2·6 resections per year). The nationwide mortality rate was 6·2 per cent, increasing progressively from 3·1 per cent in very high-volume to 10·6 per cent in very low-volume hospitals. For the purposes of centralization, applying a minimum volume threshold of at least ten resections per year would lead to selection of 92 facilities, with an overall mortality rate of 5·3 per cent. However, the mortality rate would exceed 5 per cent in 48 hospitals and be greater than 10 per cent in 17. If the minimum volume were 25 resections per year, the overall mortality rate would be 4·7 per cent in 38 facilities, but still over 5 per cent in 17 centres and more than 10 per cent in five. The combination of a volume requirement (at least 10 resections per year) with a mortality threshold (maximum RSMR 5 or 10 per cent) would allow exclusion of facilities with unacceptable results, yielding a lower overall mortality rate (2·7 per cent in 45 hospitals or 4·2 per cent in 76 respectively). CONCLUSION: The best performance model for centralization involved a threshold for volume combined with a mortality threshold.

ANTECEDENTES: Los beneficios de la centralización de la cirugía pancreática están bien documentados, pero la política de actuación difiere entre los países. Este estudio tuvo como objetivo desarrollar modelos de centralización basados en varios criterios y analizar su aplicación en una cohorte nacional. MÉTODOS: Los datos de todas las resecciones pancreáticas realizadas entre 2014 y 2016 se obtuvieron del Ministerio de Salud italiano. La mortalidad se evaluó para diferentes categorías del volumen hospitalario y para cada centro individualmente. Se calculó la mortalidad observada y la tasa estandarizada de riesgo de mortalidad (risk standardized mortality rate, RSMR). Se analizaron varios modelos de centralización aplicando criterios de volumen solos o en combinación con umbrales de mortalidad. RESULTADOS: Un total de 395 hospitales realizaron 12.662 resecciones; 305 de ellos pertenecían a la categoría de muy bajo volumen (media de 2,6 resecciones/año). La mortalidad nacional fue del 6,2%, aumentando progresivamente del 3,1% en los hospitales de muy alto volumen al 10,6% en los hospitales de muy bajo volumen. Para fines de centralización, al aplicar un umbral de volumen mínimo ≥ 10 resecciones/año, se seleccionarían 92 centros, con una mortalidad global del 5,3%. Sin embargo, la mortalidad sería > 5% en 48 hospitales y > 10% en 17 hospitales. Si el volumen mínimo fuera de 25 resecciones/año, la mortalidad global sería del 4,7% en 38 hospitales, pero aún > 5% en 17 centros y > 10% en seis centros. La combinación de un volumen necesario (≥ 10 resecciones/año) con un umbral de mortalidad (RSMR ≤ 5% o ≤ 10%) permitiría excluir hospitales con resultados inaceptables, determinando una mortalidad global más baja (2,7% en 45 hospitales o 4,2% en 76 hospitales, respectivamente). CONCLUSIÓN: El mejor modelo para la centralización de resecciones pancreáticas incluyó un umbral para el volumen hospitalario combinado con un umbral de mortalidad.

Enhanced recovery pathways in colorectal surgery: a consensus paper by the Associazione Chirurghi Ospedalieri Italiani (ACOI) and the PeriOperative Italian Society (POIS).

Enhanced Recovery After Surgery (ERAS) pathway is a multi-disciplinary, patient-centered protocol relying on the implementation of the best evidence-based perioperative practice. In the field of colorectal surgery, the application of ERAS programs is associated with up to 50% reduction of morbidity rates and up to 2.5 days reduction of postoperative hospital stay. However, widespread adoption of ERAS pathways is still yet to come, mainly because of the lack of proper information and communication. Purpose of this paper is to support the diffusion of ERAS pathways through a critical review of the existing evidence by members of the two national societies dealing with ERAS pathways in Italy, the PeriOperative Italian Society (POIS) and the Associazione Italiana Chirurghi Ospedalieri (ACOI), showing the results of a consensus development conference held at Matera, Italy, during the national ACOI Congress on June 10, 2019.

Effect of sarcopenia and visceral obesity on mortality and pancreatic fistula following pancreatic cancer surgery.

BACKGROUND: Analytical morphometric assessment has recently been proposed to improve preoperative risk stratification. However, the relationship between body composition and outcomes following pancreaticoduodenectomy is still unclear. The aim of this study was to assess the impact of body composition on outcomes in patients undergoing pancreaticoduodenectomy for cancer. METHODS: Body composition parameters including total abdominal muscle area (TAMA) and visceral fat area (VFA) were assessed by preoperative staging CT in patients undergoing pancreaticoduodenectomy for cancer. Perioperative variables and postoperative outcomes (mortality or postoperative pancreatic fistula) were collected prospectively in the institutional pancreatic surgery database. Optimal stratification was used to determine the best cut-off values for anthropometric measures. Multivariable analysis was performed to identify independent predictors of 60-day mortality and pancreatic fistula. RESULTS: Of 202 included patients, 132 (65·3 per cent) were classified as sarcopenic. There were 12 postoperative deaths (5·9 per cent), major complications developed in 40 patients (19·8 per cent) and pancreatic fistula in 48 (23·8 per cent). In multivariable analysis, a VFA/TAMA ratio exceeding 3·2 and American Society of Anesthesiologists grade III were the strongest predictors of mortality (odds ratio (OR) 6·76 and 6·10 respectively; both P < 0·001). Among patients who developed major complications, survivors had a significantly lower VFA/TAMA ratio than non-survivors (P = 0·017). VFA was an independent predictor of pancreatic fistula (optimal cut-off 167 cm(2) : OR 4·05; P < 0·001). CONCLUSION: Sarcopenia is common among patients undergoing pancreaticoduodenectomy. The combination of visceral obesity and sarcopenia was the best predictor of postoperative death, whereas VFA was an independent predictor of pancreatic fistula.

Randomized clinical trial of laparoscopic versus open left colonic resection.

BACKGROUND: The main aim of this study was to compare short-term results and long-term outcomes of patients undergoing laparoscopic versus open left colonic resection. METHODS: Between February 2000 and December 2004, all adult patients undergoing elective left colonic resection were assessed for eligibility to the study. The protocol for postoperative care was the same in both groups. Cost-benefit analysis was based on hospital costs. Quality of life, long-term morbidity and 5-year survival were also evaluated. RESULTS: Some 268 patients undergoing left colonic resection were assigned randomly to the laparoscopic (n = 134) or open (n = 134) approach. The short-term morbidity rate was 20.1 per cent in the open group and 11.9 per cent in the laparoscopic group (P = 0.094). Hospital stay was longer in the open group (8.7 versus 7.0 days for the laparoscopic approach; P = 0.002). Cost-benefit analysis showed an additional cost of euro66 per patient randomly allocated to the laparoscopic group. Quality of life was significantly improved in the laparoscopic group 6 months after surgery, but no difference was found subsequently. The long-term morbidity rate was 11.9 per cent in the open group and 7.5 per cent in the laparoscopic group (P = 0.413). The 5-year survival rate of patients with cancer was 66 and 72 per cent for open and laparoscopic groups respectively (P = 0.321). CONCLUSION: Laparoscopic left colonic resection resulted in an earlier recovery after surgery. As cost-benefit analysis and long-term follow-up showed similar results, the laparoscopic approach should be preferred to open surgery.