Extending Quality Improvement for Pancreatoduodenectomy Within the High-Volume Setting: The Experience Factor

Cannas, S.; Casciani, F.; Vollmer, C. M.; Fisher, W. E.; Van Buren, G.; Callery, M. P.; Kent, T. S.; Pratt, W. B.; Watkins, A. A.; House, M. G.; Beane, J. D.; Berger, A. C.; Wolfgang, C. L.; Javed, A. A.; Poruk, K. E.; Soares, K. C.; Valero, V.; Fernandez-Del Castillo, C.; Fong, Z. V.; Asbun, H. J.; Stauffer, J. A.; Bloomston, M. P.; Dilhoff, M. E.; Haverick, E. N.; Schmidt, C. R.; Christein, J. D.; Hollis, R. H.; Ball, C. G.; Dixon, E.; Hughes, S. J.; Drebin, J. A.; Ecker, B.; Lewis, R.; Trudeau, M. T.; Mcmillan, M.; Miller, B.; Puri, P.; Seykora, T.; Sprys, M. J.; Zureikat, A. H.; Kowalsky, S. J.; Behrman, S. W.; Bassi, C.; Maggino, L.; Malleo, G.; Salvia, R.; Savegnago, G.; Cinelli, L.; Falconi, M.; Partelli, S.; Dickson, E. J.; Jamieson, N. B.; Velu, L. K. P.; Salem, R. R.; Kunstman, J. W.

doi:10.1097/SLA.0000000000006060

Objective: To analyze the association of a surgeon's experience with postoperative outcomes of pancreatoduodenectomies (PDs) when stratified by Fistula Risk Score (FRS). Background: Centralization is now well-established for pancreatic surgery. Nevertheless, the benefits of individual surgeon's experience in high-volume settings remain undefined. Methods: Pancreatoduodenectomies performed by 82 surgeons across 18 international specialty institutions (median: 140 PD/year) were analyzed. Surgeon cumulative PD volume was linked with postoperative outcomes through multivariable models, adjusted for patient/operative characteristics and the FRS. Then, surgeon experience was also stratified by the 10, previously defined, most clinically impactful scenarios for clinically relevant pancreatic fistula (CR-POPF) development. Results: Of 8189 PDs, 18.7% suffered severe complications (Accordion≥3), 4.8% were reoperated upon and 2.2% expired. Although the most experienced surgeons (top-quartile; >525 career PDs) more often operated on riskier cases, their experience was significantly associated with declines in CR-POPF (P<0.001), severe complications (P=0.008), reoperations (P<0.001), and length of stay (LOS) (P<0.001) - accentuated even more in the most impactful FRS scenarios (2830 patients). Risk-adjusted models indicate male sex, increasing age, ASA class, and FRS, but not surgeon experience, as being associated with severe complications, failure-to-rescue, and mortality. Instead, upper-echelon experience demonstrates significant reductions in CR-POPF (OR 0.66), reoperations (OR 0.64), and LOS (OR 0.65) in moderate-to-high fistula risk circumstances (FRS≥3, 68% of cases). Conclusions: At specialty institutions, major morbidity, mortality, and failure-to-rescue are primarily associated with baseline patient characteristics, while cumulative surgical experience impacts pancreatic fistula occurrence and its attendant effects for most higher-risk pancreatoduodenectomies. These data also suggest an extended proficiency curve exists for this operation.

Extending Quality Improvement for Pancreatoduodenectomy Within the High-Volume Setting: The Experience Factor / Cannas, S.; Casciani, F.; Vollmer, C. M.; Fisher, W. E.; Van Buren, G.; Callery, M. P.; Kent, T. S.; Pratt, W. B.; Watkins, A. A.; House, M. G.; Beane, J. D.; Berger, A. C.; Wolfgang, C. L.; Javed, A. A.; Poruk, K. E.; Soares, K. C.; Valero, V.; Fernandez-Del Castillo, C.; Fong, Z. V.; Asbun, H. J.; Stauffer, J. A.; Bloomston, M. P.; Dilhoff, M. E.; Haverick, E. N.; Schmidt, C. R.; Christein, J. D.; Hollis, R. H.; Ball, C. G.; Dixon, E.; Hughes, S. J.; Drebin, J. A.; Ecker, B.; Lewis, R.; Trudeau, M. T.; Mcmillan, M.; Miller, B.; Puri, P.; Seykora, T.; Sprys, M. J.; Zureikat, A. H.; Kowalsky, S. J.; Behrman, S. W.; Bassi, C.; Maggino, L.; Malleo, G.; Salvia, R.; Savegnago, G.; Cinelli, L.; Falconi, M.; Partelli, S.; Dickson, E. J.; Jamieson, N. B.; Velu, L. K. P.; Salem, R. R.; Kunstman, J. W.. - In: ANNALS OF SURGERY. - ISSN 0003-4932. - 279:6(2024), pp. 1036-1045. [10.1097/SLA.0000000000006060]