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Institutional Influence on the Surgical Management of Peri-Ampullary Adenocarcinoma
Holly Rochefort*, Lea Matsuoka, Kostantinos Chouliaras, Efstathios Karamanos, Rick Selby, Sophoclis Alexopoulos
Surgery, Keck School of Medicine of USC, Los Angeles, CA
Objectives: To evaluate the institutional effect on the outcomes following pancreaticoduodenectomy (PD) for peri-ampullary adenocarcinoma (PACa) performed by the same group of hepatobiliary/pancreatic surgeons in an academic county versus academic private setting.
Design: Retrospective review.
Setting: Academic county hospital (CH) versus academic private hospital (PH).
Patients: All patients undergoing PD from 1/1/2010 to 4/30/2012 for periampullary adenocarcinoma.
Main Outcome Measures: Time to intervention, disease stage, completeness of resection, post-operative length of stay, complication rates, and overall survival.
Results: Ninety-one patients underwent PD for PACa during the study period: 30 patients at the CH and 59 patients at the PH. No CH patients had private health insurance while only 5% of PH patients had state insurance. CH patients were significantly younger (57.3 versus 67.4 years old, p<0.01) and more frequently Hispanic (66.7% versus 21.3%, p<0.01) compared to PH patients. The mean time from surgical consultation to PD was longer for CH patients than for PH patients but did not achieve significance (35.5 days versus 22.6 days, p=0.09). PH patients had more advanced disease, defined as AJCC Stage IIb, III, or IV, compared to CH patients (73.8% versus 50.0%, p=0.02). Portal venous resection was performed in 26.2% of PH patients while no CH patients underwent portal venous or arterial resection/reconstruction. Though not achieving statistical significance, and R1 or M1 resection was more frequently performed at the PH compared to the CH (23% versus 6.7%, p=0.06). The mean tumor diameter, number of lymph nodes obtained, number of positive lymph nodes, and incidence of perineural or perivascular invasion did not differ between the two groups. No post-operative mortality was observed within 30 days of surgery. Independent predictors of mortality included presence of positive lymph nodes (adjusted OR 1.22 (1.02, 1.46), p=0.034) and increasing tumor size (adjusted OR 1.57 (1.07, 2.46), p=0.049). Interestingly, after adjusting for differences between the groups, the odds of dying for patients admitted to County Hospital were 4.21 times higher, and trended towards significance (adjusted OR 4.21 (1.00, 17.79), p=0.051).
Conclusions: The type of institution influences practice patterns in the management of peri-ampullary cancers. Private hospital patients have more advanced disease and undergo significantly more complicated resections with a higher incidence of residual disease compared to county hospital patients. Factors leading to differences in surgical practice pattern must be better understood to ensure optimal treatment for both well insured and poorly insured patient populations.
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