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Starting a Pancreatic Surgery Program At a Community Hospital: Bucking the Trend
Jeffrey Hardacre*1, Siavash Raigani2, John a. Dumot3
1Surgery, University Hospitals Case Medical Center, Cleveland, OH; 2Surgery, Case Western Reserve University School of Medicine, Cleveland, OH; 3Medicine, University Hospitals Ahuja Medical Center, Beachwood, OH
Background: Most literature suggests that pancreatic resections should be done by high-volume surgeons at high-volume hospitals to optimize patient outcomes. However, patient preference and insurance requirements may restrict hospital location. After careful planning, a high-volume pancreatic surgeon started performing pancreatectomies at a community hospital.
Methods: During a 14-month period, 81 pancreatectomies were performed, 60 at an academic medical center (AMC) and 21 at a 144-bed community, non-teaching hospital (CH) which has 24-hr in-house intensivists and has interventional gastroenterology/radiology services. Patients were selected for surgery at the community hospital based on insurance carrier, health status, anticipated difficulty of resection, and patient preference. The operations performed at the community hospital were done with the help of a senior/chief surgical resident; however all post-operative care was provided by the attending surgeon without the help of residents or mid-level providers. Sixty-day outcomes were recorded.
Results: There were no statistically significant differences between the AMC and CH with regard to the median age of the patients (66 vs 59 years), the gender distribution (57% vs 62% female), or the median BMI (28 vs 25 kg/m2).There was a significant difference in the American Society of Anesthesiologists (ASA) class distribution between the AMC and CH (1: 0% vs 5%, 2: 7% vs 24%, 3: 88% vs 71%, 4: 5% vs 0%, p=0.0039). Operations and outcomes are shown in the table. For pancreaticoduodenectomy (PD)/total pancreatectomy (TP) patients operated on at the CH, estimated blood loss (EBL), operative time, and length of stay (LOS) were significantly less than for patients at the AMC. For distal pancreatectomy/splenectomy (DPS) patients at the CH, the lower EBL and particularly the shorter LOS are clinically relevant, but not statistically significant. Major complications and readmissions tended to be lower at the CH. Greater than 80% of patients with adenocarcinoma at both hospital settings who were recommended to receive adjuvant therapy started their treatment within 60 days of surgery.
Conclusions: With appropriate planning and careful patient selection, high-quality pancreatic surgery can be performed at a community hospital by a high-volume pancreatic surgeon.
| AMC (N=60) | CH (N=21) | p value | | | | | | Operation | | | 0.99 | | PD | 33 (55%) | 12 (57%) | | | TP | 6 (10%) | 2 (10%) | | | DPS | 21 (35%) | 7 (33%) | | | | | | | Median EBL (ml) | | | | | PD/TP | 650 | 250 | 0.0048 | | DPS | 300 | 50 | 0.18 | | | | | | Median Operative Time (min) | | | | | PD/TP | 388 | 329 | 0.0023 | | DPS | 164 | 156 | 0.17 | | | | | | Median LOS (days) | | | | | PD/TP | 7 | 5 | 0.012 | | DPS | 5 | 3 | 0.25 | | | | | | Accordion ≥ 3 Complication | | | | | PD/TP | 10 (26%) | 2 (14%) | 0.48 | | DPS | 6 (29%) | 0 | 0.16 | | | | | | Readmission | | | | | PD/TP | 7 (18%) | 2 (14%) | 0.76 | | DPS | 6 (29%) | 1 (14%) | 0.45 | | | | | | Started Adjuvant Therapy (adenocarcinoma patients) | 26 of 31 (84%) | 14/15 (93%) | 0.37 | | | | | | | | |
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