Pancreaticoduodenectomies in a Low Volume, Small Island Eastern Caribbean State: A Retrospective Cohort Study

Main Article Content

Shamir O Cawich Greg Padmore Sahle Griffith Karisha Hinkson-LaCorbiniere Reena Patel

Abstract

Background: Although pancreaticoduodenectomy (PD) is safe when performed in high-volume hospitals, many patients in low-income countries cannot access these hospitals. Barbados is a small island that does not have a high-volume pancreatic center. We sought to document peri-operative outcomes when PD was performed in Barbados.


Methods: We carried out a retrospective cohort study of all consecutive patients who underwent PDs over from August 1, 2016 to October 30, 2022. Therapeutic outcomes, post-operative morbidity and mortality were evaluated. Statistical analyses were performed using SPSS ver 16.0.


Results: Six patients at a mean age of 54.8 years underwent PD (mean annual case volume of 1). Two patients underwent planned vein resections and reconstruction. In this subset, the mean operating time was 325 minutes (Range 300-250; Median 325; SD ±35.4), mean estimated blood loss was 825mls (Range 750-900; Median 825; SD±106.1), and the mean transfusion requirement was 1 unit of packed cells (Range 0-2; Median 1; SD±1.41).


In the four patients without vein resection, mean operating time was 308 minutes (Range 280-350; Median 300; SD±24.01), median blood loss was 575 ml (Range 150-900; Median 700; SD±320.6) and mean transfusion requirements were 0.5 units of packed cells (Range 0-2; Median 0; SD ±0.84).


The mean ICU stay was 2.17 days (Range 1-3; Median 2.5; SD±0.98), and the mean duration of hospitalization was 9.3 days (Range 7-11; Median 9.5; SD±1.37). There were no recorded peri-operative deaths, but there was 1 (17%) minor complication (delayed gastric emptying) and 1 (17%) major complication (myocardial infarction).


Conclusion:  In Barbados, there are good peri-operative outcomes after PD despite the low volume and challenging healthcare environment. We believe that (1) surgeon experience (2) continuous adaptive hospital learning and (3) regular audit of hospital data are better indicators of PD quality than volume data alone.

Keywords: Pancreas, Surgery, Pancreatectomy, Whipple, Pancreaticoduodenectomy

Article Details

How to Cite
CAWICH, Shamir O et al. Pancreaticoduodenectomies in a Low Volume, Small Island Eastern Caribbean State: A Retrospective Cohort Study. Medical Research Archives, [S.l.], v. 11, n. 6, june 2023. ISSN 2375-1924. Available at: <https://esmed.org/MRA/mra/article/view/3893>. Date accessed: 08 dec. 2024. doi: https://doi.org/10.18103/mra.v11i6.3893.
Section
Research Articles

References

1. Soreide JA, Sandvik OM, Soreide K. Improving pancreas surgery over time: Performance factors related to transition of care and patient volume. International Journal of Surgery. 2016; 32: 116-122
2. Schmidt CM, Turrini O, Parikh P, House MG, Zyromski NJ, Nakeeb A, Howard TJ, Pitt HA, Lillemoe KD. Effect of Hospital Volume, Surgeon Experience, and Surgeon Volume on Patient Outcomes After Pancreaticoduodenectomy: A Single-Institution Experience. Arch Surg. 2010; 145(7): 634-640
3. Fong Y, Gonen M, Rubin D, Radzyner M, Brennan MF. Long-Term Survival Is Superior After Resection for Cancer in High-Volume Centers. Ann Surg. 2005; 242: 540-7
4. Neoptolemos JP, Russell RC, Bramhall S, Theis B. Low mortality following resection for pancreatic and periampullary tumours in 1026 patients: UK survey of specialist pancreatic units. UK Pancreatic Cancer Group. Br J Surg. 1997; 84: 1370 –1376.
5. Cawich SO, Kluger MD, Francis W, Deshpande RR, Mohammed F, Bonadie KO, Thomas DA, Pearce NW, Schrope BA. Review of minimally invasive pancreas surgery and opinion on its incorporation into low volume and resource poor centres. World J Gastrointest Surg. 2021; 13(10): 1122-1135
6. Griffith SP. Laparoscopic Colectomy: Oncologic Principles. J Carib Coll Surg. 2017; 1(S1): 20.
7. Griffith SP, Cawich SO, Mencia MM, Naraynsingh V, Pearce NW. Laparoscopic Liver Resection by Distance Mentoring - Trinidad to Barbados: A Report Curues. 2019;11(9):e5796. DOI: 10.7759/cureus.5796.
8. Cawich SO, Simpson LK, Josephs A. Laparoscopic Hepatectomy via Remote Mentoring From Jamaica to Trinidad. Cureus. 2021; 13(12): e20177.
9. Cawich SO, Pearce NW, Naraynsingh V, Shukla P, Deshpande RR. Whipple’s operation with a modified centralization concept: A model in low-volume Caribbean centers. World J Clin Cases 2022; 10(22): 7620-7630
10. Teoule P, Bartel F, Birgin E, Ruckert F, Wilhelm TJ. The Clavien-Dindo Classification in Pancreatic Surgery: A Clinical and Economic Validation. J Invest Surg. 2018;16:1-7
11. van Heek NT, Kuhlmann KFD, Scholten RJ, de Castro SM, Busch ROC, van Gulik TM, Obertop H, Gouma DJ. Hospital Volume and Mortality After Pancreatic Resection: A Systematic Review and an Evaluation of Intervention in The Netherlands. Ann Surg. 2005; 242(6): 781-790
12. Kuhlmann KF, de Castro SM, Wesseling JG, tenKate FJW, Offerhaus GJA, Busch ORC, van Gulik TM, Obertop H, Gouma DJ. Surgical treatment of pancreatic adenocarcinoma; actual survival and prognostic factors in 343 patients. Eur J Cancer. 2004; 40: 549–558
13. Gilsdorf RB, Spanos P. Factors influencing morbidity and mortality in pancreaticododenectomy. Ann Surg. 1973; 177: 332-337
14. Lansing PB, Blalock JB, Oschner JL. Pancreaticoduodenectomy: a retrospective review, 1949-1969. Am Surg 1972; 38: 79-86 [PMID: 4333406]
15. Sosa JA, Bowman HM, Gordon TA, Bass EB, Yeo CG, Lillemoe KD, Pitt HA, Tielsch JM, Cameron JM. Importance of hospital volume in the overall management of pancreatic cancer. Ann Surg. 1998; 228(3): 429-438
16. Kotwall CA, Maxwell JG, Brinker CC, Koch GG, Covington DL. National estimates of mortality rates for radical pancreaticoduodenectomy in 25,000 patients. Ann Surg Oncol. 2002; 9(9): 847-854
17. Ho V, Heslin MJ. Effect of hospital volume and experience on in-hospital mortality for pancreaticoduodenectomy. Ann Surg. 2003; 237(4): 509-514
18. Billimora KY, Bentrem DJ, Feinglass JM, Stewart AK, Winchester DP, Talamonti MS, Ko CY. Comparison of Perioperative Mortality and Long-Term Survival for Cancer Surgery. J Clin Oncol. 2008; 26: 4624-4633
19. Mayo SC, Gilson MM, Herman JM, Cameron JL, Nathan H, Edil BH, Choti MA, Schulik RD, Wolfgang CL, Pawlik TM. Management of patients with pancreatic adenocarcinoma: national trends in patient selection, operative management, and use of adjuvant therapy. J Am Coll Surg. 2012; 214(1): 33-45
20. Simianu VV, Zyromski NJ, Nakeeb A, Lillemoe KD. Pancreatic cancer: progress made. Acta Oncol. 2010; 49(4): 407-417
21. Lassen K, Ljungqvist LO, Dejong CH, Demartines N, Parks RW, Lobo DN, Coolsen MME, Fearon KCH. Pancreaticoduodenectomy: ERAS recommendations. Clin Nutr. 2013; 32(5): 870-871
22. Bliss LA, Yang CJ, Chau Z, Ng SC, McFadden DW, Kent TS, Moser AJ, Callery MP, Tseng JF. Patient selection and the volume effect in pancreatic surgery: unequal benefits? HPB 2014; 16: 899–906
23. Derogar M, Blomberg J, Sadr-Azodi O. Hospital teaching status and volume related to mortality after pancreatic cancer surgery in a national cohort. BJS 2015; 102: 548–557.
24. Birkmeyer JD, Warshaw AL, Finlayson SR, Grove MR, Tosteson AN. Relationship between hospital volume and late survival after pancreaticoduodenectomy. Surg. 1999; 126(2): 178-183 [PMID: 10455881]
25. McPhee JT, Hill JS, Whalen GF, Zayaruzny M, Litwin DE, Sullivan ME, Anderson FA, Tseng JF. Perioperative mortality for pancreatectomy: a national perspective. Ann Surg. 2007; 246: 246–253
26. Gordon TA, Bowman HM, Tielsch JM, Bass EB, Burleyson GP, Cameron JL. Statewide regionalization of pancreaticoduodenectomy and its effect on in-hospital mortality. Ann Surg. 1998; 228: 71–78
27. Alsfasser G, Kittner J, Eisold S, Klar E. Volume-outcome relationship in pancreatic surgery: the situation in Germany. Surgery. 2012; 152(3S1): 50–55
28. Glasgow RE, Mulvihill SJ. Hospital Volume Influences Outcome in Patients undergoing pancreatic resection for cancer. West J Med. 1996; 165(5): 294-300.
29. Briceno P, Hutson J, Shridhar R, Meredit K. Pancreatic Resection at High Volume Centers Improves Survival. HPB. 2017; S171(19): 131.
30. Riall TS, Eschbach KA, Townsend CM, Nealon WH, Freeman JL, GoodwinJS. Trends and disparities in regionalization of pancreatic resection. J Gastrointest
Surg. 2007; 11(10): 1242-1252
31. Ho CK, Kleef J, Friess H, Buchler MW. Complications of Pancreatic Surgery. HPB. 2005; 7(2): 99-108.
32. Bouvet M. Comment on the effect of Hospital Volume, Surgeon Experience, and Surgeon Volume on Patient Outcomes After Pancreaticoduodenectomy: A Single-Institution Experience. Arch Surg. 2010; 145(7): 640.
33. Gasper WJ, Glidden DV, Jin C, Way LW, Patti MG. Has recognition of the relationship between mortality rates and hospital volume for major cancer surgery in California made a difference? A follow-up analysis of another decade. Ann Surg. 2009; 250(3): 472-83
34. Hashimoto DA, Bababekov Y, Mehtsun WT, Stapleton SM, Warshaw AL, Lillemoe KD, Chang DC, Vagefi PA. Is Annual Volume Enough? The Role of Experience and Specialization on Inpatient Mortality After Hepatectomy. Ann Surg. 2017; 266(4): 603-9
35. Ihse I. The volume-outcome relationship in cancer surgery: a hard sell. Ann Surg. 2003; 238: 777–781