Patients with pancreatic ductal adenocarcinoma whose pancreatoduodenectomy is converted to an open (CTO) procedure from a minimally invasive procedure as a result of complications may fare better at institutions that perform more minimally invasive pancreatic cancer surgeries annually, according to a new study published by Villano et al in The American Journal of Surgery.
Background
Pancreatic ductal adenocarcinoma—the seventh leading cause of cancer mortality worldwide—is the most common type of pancreatic cancer. Treatment typically requires pancreatoduodenectomy, also known as a Whipple procedure, a complex surgery to remove the head of the pancreas, the gallbladder, the bile duct, part of the small intestine, and sometimes a portion of the stomach.
To improve patient outcomes, clinicians have moved toward using minimally invasive laparoscopic or robotic methods of surgery when performing these procedures. However, previous studies have shown that when complications force a surgical team to stop the minimally invasive procedure and move to a CTO procedure, those patients have worse postoperative outcomes than if they had open surgery from the start.
“The repercussions of [moving to CTO] surgery are highest at lower-volume centers with less experience, and these downstream effects are mitigated quite a bit if you go to a hospital that does a high volume of these procedures,” highlighted lead study author Anthony Villano, MD, Clinical Instructor of Surgical Oncology in the Division of General Surgery at the Fox Chase Cancer Center. “Outcomes tend to be best at places that have more experience with this procedure,” he added.
Study Methods and Results
Using 8 years of data from the National Cancer Database, Dr. Villano and colleagues examined the survival rates of patients with nonmetastatic pancreatic ductal adenocarcinoma following their pancreatoduodenectomies.
The researchers divided the patients by surgery type—open surgery, successful minimally invasive surgery, and minimally invasive surgery moved to a CTO procedure—and found that patients whose surgery was moved to a CTO procedure had worse short-term morbidity and mortality than patients in the other two groups. Additionally, long-term survival was worse in patients who underwent a CTO procedure compared with those who underwent a successful minimally invasive or open surgery from the start.
The researchers then compared the patients’ outcomes based on the hospitals where they were treated; hospitals that performed more than 10 minimally invasive pancreatoduodenectomies each year were deemed high-volume centers, and those that performed fewer were deemed low-volume centers.
When the patient’s CTO procedure occurred at a low-volume center, they continued to have significantly worse short- and long-term mortality than patients who underwent a successful minimally invasive surgery. However, at high-volume centers, this effect was mitigated and survival rates were similar across all three patient groups.
Conclusions
The researchers emphasized that to improve patient outcomes, the next step is to identify the factors contributing to the disparity in survival rates for patients whose surgery was moved to a CTO procedure.
“What’s the ‘secret sauce’ at the higher-volume centers? What are they doing differently that the low-volume centers are not? Experience is one factor, but I think there are many more, and we don’t know them all,” Dr. Villano emphasized.
The researchers concluded that their findings revealed the significance of safe adoption strategies for surgeons who are learning how to successfully perform minimally invasive pancreatoduodenectomies.
Disclosure: For full disclosures of the study authors, visit americanjournalofsurgery.com.
